THE 

ENDOCRINES 


BY 

SAMUEL  WYLLIS  BANDLER,  A.B.,  M.D.,  F.A.C.S. 

Professor  of  Gynecology  in  the  New  York  Post-Graduate  Medical  School 
and  Hospital 


^ 


PHILADELPHIA    AND  LONDON 

W.    B.    SAUNDERS    COMPANY 

1920 


^ 


Copyright,  1920,  by  W.  B.  Saunders  Company 


'Biz- 


PRINTED    IN    AMERICA 

PRESS   OF 

W.     B.     SAUNDERS    COMPANY 

PHILADELPHIA 


PREFACE 


Heredity  is  the  most  profound  factor  in  life.  En- 
vironment is  an  ever  present  influence.  Physiological 
functions  have  a  well  recognized  normal  basis,  and  devia- 
tions therefrom  come  under  the  head  of  the  abnormal  or 
pathological.  A  continuous  struggle  against  bacteria 
calls  into  play  the  protective  and  defensive  mechanism  of 
the  body.  In  this  struggle,  as  well  as  in  the  fight  against 
new  growths,  not  only  are  the  principles  of  physiological 
chemistry  and  bio-chemistry  to  be  considered,  but  like- 
wise the  defense  and  protection  supplied  by  what  are 
known  as  the  ductless  glands.  Congenital  and  heredi- 
tary deviations  in  the  functions  of  the  ductless  glands, 
altered  inter-relations  at  different  physiological  periods, 
the  attacks  of  bacteria,  environment,  etc.,  are  productive 
of  many  physical,  mental  and  psychic  abnormalities. 
Heredity,  the  effects  of  environment,  and  many  of  the 
states  of  mankind  can  be  properly  appreciated  only  by 
an  understanding  of  endocrine  activity  and  inter- 
relation. 

The  development  of  the  tissues  and  structures  of  the 
body,  the  normal  development  of  the  cerebro-spinal  sys- 
tem, the  proper  functioning  of  the  various  structures  and 
tissues  are  all  intimately  connected  with  the  work  of  the 
ductless  glands.  The  function  of  the  all  important  auto- 
nomic nervous  system  depends  much,  if  not  entirely,  on 
a  proper  balance  of  the  endocrine  system.  Mental  states, 
psychoses,  neuroses,  abnormal  as  well  as  normal  be- 
havior, are  all  quite  as  closely  related  to  these  important 


111 


IV  PREFACE 

ductless  structures.  If  we  are,  in  the  final  analysis,  very 
much  the  expression  of  the  activities  of  the  endocrines 
on  the  autonomic  nervous  S3^stem  and  on  our  instincts  and 
emotions,  and  if  our  instincts  and  emotions  are  deeply 
related  to  the  endocrines,  then  mens  sanis  in  cor  pore  sano 
takes  on  an  added  significance.  The  subconscious  state 
is  intimately  linked  with  the  instincts  and  emotions.  How 
much  closer  to  the  true  and  wholesome  are  we  led  by 
these  facts  than  by  the  aberrations  of  the  theories  of 
Freud. 

What  is  known  of  the  endocrine  glands  is  bearing 
more  than  sufficient  root  to  form  a  working  basis  for  the 
understanding  of  these  numerous  hereditary,  physical  and 
psychic  questions.  Only  by  therapy  and  by  the  use  of  the 
extracts  of  these  glands  can  we  be  led  to  definite  con- 
clusions. Hence,  every  practicing  physician  has  in  his 
hands  the  material  with  which  he  may  lend  aid  in  the 
research  along  these  lines. 

It  is  in  the  hopes  of  putting  the  basic  principles  of 
endocrinology  and  many  of  the  questions  which  hold  out 
promise  of  solution  into  the  hands  of  interested  medical 
men  that  this  work  has  been  put  into  print.  I  have  drawn 
from  the  works  of  Gushing,  Biedl,  Knauer,  Falta,  Daven- 
port, Guyer,  Gannon,  ]\IcDougall  and  others,  giving 
credit  wherever  possible.  Alany  of  these  authorities  were 
consulted  and  studied  years  ago.  IMuch  of  what  was 
originally  viewed  with  skepticism  is  now  generally  ac- 
cepted as  current  truth.  Whatever  of  theory  is  printed 
in  these  pages  represents  an  attempt  at  a  solution  of 
vexing  problems.  It  would  be  idle  to  claim  that  there 
may  be  no  change  in  some  of  these  theories,  but  a  begin- 
ning must  be  made,  and  while  a  beginning  is  made  with 
hesitation,  these  opinions  are  offered  on  the  basis  of 
therapy  fortified  by  clinical  observation.     If  in  so  many 


PREFACE  V 

fields  the  results  of  therapy  are  as  favorable  as  they  would 
seem,  this  effort  too  has  been  worth  while.  If  the  factors 
which  suggest  the  relation  of  the  endocrines.  among 
them  adrenal  cortex  and  especially  pituitary  gland,  to 
fibromyomata  prove  other  than  visionary,  then  the  pos- 
sible solution  of  the  etiology  of  malignant  growths  will 
be  hastened. 

S.  Wyllis  Bandler. 
134  W.  87th  St., 

New  York  City. 
November,  ip20. 


CONTENTS 


PAGE 

CHAPTER  I 
Introductory  i 

CHAPTER  II 
Environment  and  Heredity 4. 

CHAPTER  III 
An  Introduction  to  the  Story  of  the  Endocrines 56 

CHAPTER  IV 
Internal   Secretions 93 

CHAPTER  V 
The  Endocrines  in  Gynecology 135 

CHAPTER  VI 
Hypergenitalism  and  Hypogenitalism 150 

CHAPTER  Vll 

Skin  Affections  and  the  Internal  Secretions 158 

CHAPTER  VIII 

PuBERTi-    AND    CLIMACTERIUM l6l 

CHAPTER  IX 
The  "Higher  Up"  Theory  of  Sterility  in  Women  and  Its  Relation 
TO  the  Endocrines 171 

CHAPTER  X 

Pregnancy,  Labor,  and  the  Placental  Gland 196 

CHAPTER  XI 
Constitutional    Dysmenorrhea 218 

CHAPTER  XII 

Instincts  and  Emotions 232 

CHAPTER  XIII 

Mental  and  Nervous  Defects 250 

vii 


Vlil  CONTENTS 

PAGE 
CHAPTER  XIV 
Mental  Deficiency  and  Criminality 257 

CHAPTER  XV 
Neuroses  and  Psychoses 267 

CHAPTER  XVI 
Phobias    271 

CHAPTER  XVII 
The  Autonomic  Nervous  System 280 

CHAPTER  XVIII 
The    Balance    Between    the    Endocrines    and    in    Each    Individuai 

Endocrine 287 

CHAPTER  XIX 
Therapeutic  Suggestions  Concerning  Endocrines 31+ 

CHAPTER  XX 
The  History  and  the  Symptoms 33i 

CHAPTER  XXI 
Clinics  • 355 

CHAPTER  XXII 
Cases • 397 

Index    477 


THE  ENDOCRINES 

CHAPTER  I 

INTRODUCTORY 

Medical  training  may  have  its  faults  on  the  anatomical 
and  laboratory  side  of  its  teaching,  in  that  it  demands  too  much 
time  and  attention  to  these  points  to  the  exclusion  of  suf- 
ficient information  and  knowledge  concerning  the  individual, 
his  instincts,  his  emotions  and  his  psyche.  Too  many  men 
are  imbued  with  the  notion  that  the  laboratory  side  is  the 
all  important  and  while  histology,  pathology,  physiological 
chemistry,  the  various  blood,  metabolic  and  other  tests  are  oi 
the  greatest  importance  in  adding  to  our  knowledge  and  in 
aiding  our  diagnosis,  the  intensive  study  of  and  devotion  to 
these  branches  are  and  must  remain  within  the  province  of 
men  devoted  to  that  particular  type  of  work;  and  while  the 
physician  must  understand  the  importance  of  these  examina- 
tions and  tests  and  must  of  course  be  able  to  interpret  their 
meaning,  he  should  not  neglect  and  must  not  neglect  the 
study  of  human  nature,  of  psychology,  peculiarities  of  physical, 
mental  and  psychic  type,  the  study  of  the  endocrines,  etc.,  the 
interpretation  of  which  ought  to  be  given  to  him  by  no  one 
but  himself  when  applied  to  each  case  in  his  practice,  Th€ 
old-fashioned,  kindly  physician  we  recall  from  our  boyhood 
days,  the  country  practitioner,  brought  up  in  a  small  com- 
munity, the  man  whose  childhood  and  environment  brought 
him  into  close  contact  with  all  sorts  of  people  whose  past  and 
present  he  understood,  without  knowing  at  the  time  that  he 
did  understand ;  the  man  with  the  innate  power  to  understand 
and  analyze  human  beings  possesses  no  mean  advantage  over 
the  type  of  physician  who  is  ultra-scientific  in  the  laboratory 
sense  and  nothing  more.  The  ideal,  of  course,  is  a  combina- 
tion of  the  two. 

1 


Z  THE    ENDOCRINES 

Of  all  men  the  physician  is  thrown  into  closest  relations 
for  the  study  of  man  and  his  ills.  It  is,  however,  no  longer 
a  question  of  examining  the  lungs,  the  heart,  the  kidneys, 
taking  the  blood  pressure,  examining  the  blood  and  then  giv- 
ing his  advice;  it  is  no  longer  a  question  of  combating  the 
various  infectious  diseases;  it  is  not  alone  a  struggle  with 
the  various  forms  of  benign  and  malignant  tumors;  it  is  no 
longer  the  practice  of  surgery  with  its  saving  of  life  and  the 
improvement  of  health;  the  physician  should  be  able  and  must 
be  able  to  understand  the  difference  between  normality  and 
abnormality  in  the  innumerable  deviations  of  body,  mind  and 
psyche  associated  with  and  due  to  the  ductless  glands.  They 
are  the  underlying  factors  in  heredity;  they  have  to  do  with 
growth  and  development  of  body  and  mind;  they  have  to  do 
with  instincts  and  emotions;  they  have  to  .do  with  normal 
and  abnormal  psychic  and  mental  states;  and  from  these  ills 
come  more  torture  and  suffering  than  anyone  but  the  phy- 
sician really  appreciates. 

The  differences  between  animals  of  various  species  are 
due  to  the  ductless  glands.  The  variations  between  animals 
of  the  same  species  are  due  to  the  ductless  glands.  Race  char- 
acteristics are  produced  and  perpetuated  by  the  same  factors, 
and  the  differences  among  individuals  of  the  same  race  like- 
wise depend  on  endocrine  activity;  and  resemblances  in  body, 
mind  or  psyche,  whether  the  resemblance  is  that  of  normality 
or  abnormality,  are  due  to  like  or  similar  relations  in  the 
activity  of  the  endocrines. 

The  instincts,  the  emotions,  their  relation  to  the  endocrines 
and,  therefore,  to  behavior  will  be  discussed  later ;  a  very  brief 
reference  to  these  most  important  questions  is  in  place.  Among 
the  more  important  instincts  and  emotions  are  (1)  The  in- 
stinct of  flight  and  the  emotion  of  fear;  (2)  The  instinct  of 
pugnacity  and  the  emotion  of  anger,  as  evidenced  by  fighting; 
(3)  The  instinct  of  self-assertion  and  the  emotion  of  elation 
evidenced  by  the  ego  and  independence;  (4)  The  instinct  of 
subjection  and  the  emotion  of  subjection,  shown  by  negative 
self-feeling;  (5)  The  instinct  of  suggestibility  shown  by  the 


INTRODUCTORY  3 

readiness  to  accept  or  to  be  taught;  (6)  The  instinct  of  con- 
trasuggestion,  which  is  one  of  the  most  determining  factors 
in  human  or  animal  Hfe;  (7)  The  sex  instinct,  which  is  quite 
different  from  (8)  the  maternal  and  the  paternal  instincts; 
(9)  The  gregarious  instinct  evidenced  by  hunting  in  packs, 
the  desire  to  be  in  company,  in  groups,  associated  with  one's 
fellows. 


CHAPTER    II 
ENVIRONMENT  AND  HEREDITY 

There  has  always  been  the  problem  of  the  relative  im- 
portance of  heredity  and  environment.  The  laws  of  heredity 
are  to  a  great  extent  known,  thanks  to  the  untiring  efforts  and 
study  of  our  still  unrecognized  scientists.  And  these  laws  are 
being  continually  verified  and  amplified.  The  laws  of  heredity 
as  to  instincts  and  emotions  are  probably  quite  the  same,  but 
since  the  instincts  and  emotions  are  so  capable  of  change,  the 
study  of  the  same  presents  a  more  difficult  problem.  Environ- 
ment is  not  the  proper  term.  It  is  not  only  the  surroundings 
and  the  conditions  and  their  character,  it  is  the  training  or  the 
treatment  a  baby,  child  or  adolescent  receives.  Neither  is 
training  the  proper  word,  for  it  calls  to  mind  the  circus  with 
its  whips  and  blows  and  show  of  power.  The  better  term  is 
treatment.  If  people  imagine  that  a  beautiful  home  and  ele- 
gant interior,  comforts  and  luxuries  are  the  heights  of  en- 
vironment and  that  this  is  all  or  the  most  essential,  they  satisfy 
themselves  and  their  consciences  only  too  readily.  It  is  the 
treatment  a  child  receives  and  the  effect  on  its  instincts  and 
emotions  that  brings  out  the  good  or  the  bad  or  represses  the 
good  or  bad.  Intelligent  treatment  can  be  as  well  carried  out 
in  modest,  wholesome  surroundings.  Even  from  the  midst 
of  poverty  the  world  sees  and  has  seen  rise  many,  if  not  most, 
of  its  best  and  marvelous  products,  because  difficulties,  obsta- 
cles, struggles,  work  and  necessity  are  related  not  only  to  the 
survival  of  the  fittest,  but  to  the  success  of  the  strong  and  the 
fighter.  The  effects  of  environment  are  important.  Children 
observe  and  imitate  and,  however  meagre  is  the  artistic  or 
aesthetic  on  the  walls,  on  the  floor  or  in  the  furniture  there 
should  be  surroundings  that  do  not  create  a  lack  of  respect 
for  the  decencies,  amenities  and  courtesies  of  life. 

The  chief  idea  in  treatment  and  education  is  to  prepare  the 
human  being  for  the  work  and  obligations  of  life  and  for 
parenthood.    Children  should  not  be  taught  that  the  main  pur- 

4 


ENVIRONMENT  AND   HEREDITY  5 

pose  of  life  is  pleasure  and  that  a  path  of  roses  will  always  be 
theirs.  They  should  be  taught  to  expect  little  and  whatever 
more  comes  to  them  is,  in  the  current  phrase,  "velvet." 

Girls  should  be  prepared  to  take  life  as  a  long  road.  Why 
should  they  in  their  earlier  years  at  home,  school,  or  boarding- 
school  center  their  thoughts  too  much  on  dress,  social  activities 
and  gaieties?  The  domestic  virtues  are  the  best  and  these 
should  be  inculcated.  When  thought  and  activity  are  centered 
too  much  on  any  one  phase,  they  exclude  action  in  other  chan- 
nels. If  occupied  with  too  many  phases  that  oppose  each 
other,  we  develop  the  jumpy  type  of  individual  looking  for  and 
desiring  change  and  excitement ;  and  while  the  instinct  of  Wan- 
derlust is  strongly  inherent  in  many  individuals,  faulty  treat- 
ment may  readily  develop  this  instinct  into  a  physical  or  men- 
tal Wanderlust  beyond  the  normal. 

When  a  man  and  woman  marry,  are  they  supposed  to 
train  each  other,  or  are  they  supposed  to  treat  each  other  ac- 
cording" to  their  respective  instincts  and  emotions  and  accord- 
ing to  the  most  sacred  principles  of  community  of  interest? 
No  one  has  a  right  to  expect  of  his  partner  more  than  that 
individual  is  capable  of  being.  Therefore  people  should  first 
know  themselves  and  should  be  taught  to  understand  others, 
for  life  in  any  of  its  relations  is  a  matter  of  give  and  take 
and  to  most  people  it  seems  to  be  a  question  of  take. 

The  treatment  a  person  receives  to  a  great  extent  deter- 
mines his  behavior  and  this  appHes  not  only  to  individuals 
but  to  groups,  communities,  states  and  nations. 

Several  children  in  the  same  family  may  have  the  same 
environment  and  if  they  receive  the  same  treatment,  possessed 
as  they  probably  are  of  different  instincts  and  emotions,  how- 
can  we  expect  like  results  ?  Not  only  have  they  inherited  dif- 
ferent physical  qualities  and  different  endocrine  relation,  but 
they  have  been  differently  affected  by  the  infectious  diseases 
of  childhood,  react  differently  to  the  same  stimuli,  and  wise 
are  the  parents  who  sense  these  facts  and  act  accordingly. 
What  right  have  we,  who  are  full  of  faults  and  weaknesses, 


6  THE    ENDOCRINES 

who  in  our  attitude  and  relation  to  others  are  often  petty  and 
ungenerous,  to  expect  in  the  growing,  immature  minds  those 
perfections  of  nature  we  so  fondly  desire  for  them,  and  what 
right  have  we  to  blame,  criticize  and  condemn  the  very 
qualities,  weaknesses  and  faults  which  we  ourselves  in  all 
probability  have  passed  on  to  them? 

Earliest  Impressions 

A  baby  cries  when  brought  into  the  world  in  contact  with 
the  air,  or  it  is  made  to  cry  by  slapping  it.  This  reaction  to 
external  stimuli  resulting  in  a  cry  is  really  the  emotion  of 
anger.'  The  newly-born  child  has  the  sensation  of  hunger  as 
perhaps  the  most  noticeable  urge.  All  infants  are  sensitive  to 
pain,  and  to  the  sense  of  the  pleasurable.  Even  in  its  earliest 
days  it  may  coo  with  all  the  notes  of  pleasure  and  contentment. 
In  the  earliest  weeks  it  fixes  its  gaze  on  the  face  of  the  nurse 
and  receives  its  first  retinal  impressions.  These  soon  form  an 
outline.  The  soft  and  the  rough  become  differentiated,  and 
repetitions  of  voice  and  the  sight  of  the  face  prompt  the  evi- 
dences of  recognition.  Perhaps  the  voice  rouses  the  first  mani- 
festation of  recognition,  although  the  really  first  habit  is  con- 
nected with  suckling.  Hearing,  the  sense  of  smell,  the  sense 
of  taste,  are  continually  recording  the  effect  of  stimuli  and 
creating  paths  of  experience.  The  skin,  the  bath,  the  powder- 
ing, the  clothing,  irritations,  an  occasional  pin  point,  the  instilla- 
tions and  washings  of  the  eyes  are  creating  new  paths.  Grad- 
ually the  ego  develops  and  soon  the  child  begins  to  assert  what 
amounts  to  a  "yes"  or  a  "no."  The  emotions  of  pleasure  and 
anger  are  aroused  extremely  early,  and  fear  is  among  the  first 
of  the  arousable  emotions.  Soon  the  baby  crawls,  learns  to 
balance  itself,  to  stand,  and  eventually  to  walk. 

Training  as  to  the  habits  associated  with  physical  func- 
tions may  yield  really  wonderful  results  at  a  very  early  period, 
though  physical  states  may  thwart  these  attempts, — especially 
as  regards  nocturnal  enuresis.  Discipline,  acting  on  the  in-^ 
stincts  and  emotions  may  influence  the  infant  according  to 
the  elements  of  subjection,  self-assertion,  suggestibility,  fear, 


ENVIRONMENT  AND  HEREDITY  V 

wonder,  curiosity,  and  so  on  through  the  whole  Hne  of  the 
simpler  and  more  complicated  or  plural  combinations. 

A  child  of  three  years  has  its  instincts  and  emotions  well 
in  evidence;  its  memory  is  excellent,  it  remembers  what  you 
promised  to  bring,  asks  questions,  wants  explanations, — 
and  is  in  most  ways  a  miniature  adult.  But  the  recall  of  this 
period  of  its  existence  is  lacking  in  later  life  because  of  the 
immaturity  of  the  cells  receiving  the  impression.  Yet  the 
mechanism  of  each  reaction  to  stimuli  on  the  part  of  the  in- 
stincts or  emotions  becomes  established  and  sensitized  so  that 
fear  of  one  or  more  sorts  may  persist  as  a  tendency  and  be 
easily  roused  after  one  or  two,  or  many  repetitions  of  the  orig- 
inal stimulus,  even  though  later  the  recall  of  the  original  stimu- 
lus does  not  exist.  But  there  comes  a  time  after  which  the  re- 
call of  incidents,  events,  and  impressions  is  developed,  and 
though  a  child  may  remember  one  fearsome  or  pleasurable 
event  as  its  first  recallable  one,  the  same  or  a  parallel  impression 
associated  with  an  emotion  of  fear  may  have  been  made  dozens 
or  a  hundred  times  before.  Therefore  the  effect  of  fear  in 
these  earlier  unremembered  years  may  be  carried  on  through 
the  remainder  of  life,  even  though,  as  just  stated,  the  first  recall 
may  date  from  a  later  period.  One  may  remember  a  book  he 
has  read  long  ago  and  may  express  his  opinion  of  it.  The 
impression  has  been  made  and  the  reader  may  consider  it  one 
of  the  most  instructive  books  he  has  read,  yet  he  may  not  con- 
nectedly recount  the  story  or  remember  the  names  of  more  than 
a  few  of  the  characters  until  they  are  brought  to  mind  by  some 
one  else,  or  by  a  rereading. 

The  earliest  experiences  of  a  child  are  the  most  important 
because  paths  are  made  by  stimuli.  These  paths  follow  a  course 
involving  the  psychic,  physical,  and  nerve  mechanism,  with  an 
associated  endocrine  reaction.  Each  path  has  been  created  by  a 
peristaltic  wave,  so  to  speak.  Such  paths  are  naturally  the 
most  sensitive  since  they  are  the  earliest,  and  the  obliteration 
of  the  once  well  established  psycho-physical  neuro-endocrine 
path  is  impossible.     The  sensitiveness  of  this  may  be  dimin- 


8  THE    ENDOCRINES 

ished  or  overshadowed,  or  no  longer  brought  into  play,  but 
what  was  once  created  as  a  path  or  groove  may  still  exist. 
With  any  such  path  there  may  be  associated  grooves  or  paths 
or  inlets  through  allied  senses,  so  that  an  impression  made  by 
any  experience  may  be  transmitted  by  sight,  through  the  skin, 
the  sense  of  smell,  taste,  or  hearing,  or  later  by  thought.  Sev- 
eral parallel  grooves  may  be  created  as  the  consequence  of  a 
stimulus,  such  as  an  event  or  an  experience.  With  each  groove 
that  is  created  there  has  been  and  is  a  connection  through  nerve 
paths  with  an  endocrine  activity, — so  that  not  only  with  the 
great  and  powerful  emotions  but  with  innumerable  of  the 
minor  ones,  and  with  the  innumerable  processes  not  viewed 
as  emotions,  there  is  not  only  a  psychic  and  a  neural  path  but 
an  associated  endocrine  process. 

If  this  be  true,  we  might  imagine  every  impression  from 
the  earliest  to  the  latest,  though  they  number  millions  and  bil- 
lions, to  have  created  a  path  from  without  inward;  and  asso- 
ciated with  these  paths  were  all  possible  degrees  of  emotions 
up  to  the  degree  evidenced  by  the  facial,  physical,  and  func- 
tional responses.  Therefore  the  reverse  of  this  would  be  an 
antiperistalic  wave,  where  by  endocrine  activity  of  any  sort, 
produced  by  digestive,  metabolic  or  other  natural  systemic 
causes,  might  reproduce  the  emotion  and  the  psychic  and 
mental  phases  of  the  original  impression.  This  might  account 
for  phobias  and  fears  which  persist,  for  inexplicable  feelings 
of  danger  and  impending  events,  troubles  or  disasters, — and 
for  dreams  and  their  associated  emotions,  whether  pleasurable 
or  fearful,  co-ordinate,  fantastic,  and  chaotic,  sexual,  or  other- 
wise. 

One  should  take  into  consideration  the  factors  of  heredity 
in  considering  the  questions  of  instincts,  emotions,  disposi- 
tion and  character  and  their  relation  to  the  endocrine  system 
and  the  psyche.  It  is  of  the  utmost  importance  to  realize  the 
effect  of  stimuli,  pleasant  or  otherwise,  on  the  emotions,  the 
mental  state,  and  the  associated  endocrine  reaction;  for  it  is 
as  certain  that  psychic  shocks  are  injurious  as  it  is  that  in- 
flammations produce, — for  instance, — a   thyroiditis  after  in- 


ENVIRONMENT  AND    HEREDITY  \) 

fluenza.  A  child  is  born  with  instincts,  emotions  and  endo- 
crines  of  a  type  contributed  by  its  parents  and  inherited  from 
them  and  their  ancestors.  Its  emotional  experiences  are  evi- 
dence of,  and  are  associated  with,  endocrine  activity.  The 
type  of  mentality  and  mental  development  are  evidences  of  nor- 
mal function,  hypofunction,  or  excessive  function, — for  in- 
stance, of  the  thyroid  and  pituitary.  Its  preference  for  certain 
forms  of  play  evidences  not  only  its  psychic  and  instinctive 
makeup,  but  often  its  physical  adaptability.  This  is,  of  course, 
susceptible  to  modification  through  education. 

Some  children  have  a  remarkable  sense  of  balance ;  others 
have  this  function  to  a  lesser  degree,  and  are  therefore  more 
timid  in  activities  requiring  its  function.  The  experiences 
in  the  aviation  service  show  that  only  those  with  a  well-devel- 
oped sense  of  balance  are  qualified  for  flying.  This  qualifica- 
tion rests  on  a  physical  basis,  having  to  do  with  the  well-recog- 
nized cerebellar  mechanism.  Many  adults  cannot  look  down 
from  a  great  height  or  follow  a  dangerous  trail  without  re- 
coiling, this  lack  of  balance  resulting  in  a  sensation  of  appre- 
hension. Thus  their  apparent  fears  rests  solely  on  a  defective 
physical  mechanism. 

Of  all  the  emotions  which  are  injurious,  fear  stands  at 
the  head.  Its  effects  in  children  are  most  pronounced,  and  if 
any  fear  becomes  fixed  it  may  have  a  lasting  effect  throughout 
life.  The  instinct  of  flight,  associated  with  the  emotion  of 
fear,  has  inlets  through  the  various  senses;  many  of  these  in- 
lets or  paths  are  performed,  but  may  be  blocked,  shifted  or 
modeled  into  a  more  pleasurable  or  less  fearful  emotion  by 
experience,  or  through  explanation,  or  by  play. 

We  must  recognize  the  relation  of  physical  states  and  In- 
stincts to  fears.  The  development  of  inhibition  or  of  switching 
may  be  exemplified  as  follows : 

A  little  boy  two  years  old  was  taken  to  Van  Cortlandt 
Park  during  a  field  day  and  was  held  in  his  father's  arms 
on  the  summit  of  a  hill  overlooking  the  parade  grounds.  A 
field  gun  boomed  with  its  noise,  its  flame,  and  its  smoke.    The 


10  'HE   ENDOCRINES 

little  child  clung  to  his  father  and  said :  "I  want  to  go  home." 
The  father  replied:  "All  right,  but  let's  hear  just  one  more 
of  those  lovely  sounds  and  watch  that  beautiful  smoke."  At 
the  next  report,  the  father  said:  "Isn't  that  lovely?  Let's 
watch  another," — and  he  jumped  up  and  down,  repeating  the 
words,  "lovely,  fine,  beautiful," — and  soon  the  child  also 
jumped  up  and  down,  repeating  these  words,  watched  the 
whole  performance,  and  was  taken  home  with  fear  changed 
to  an  emotion  of  pleasure  by  the  shunting  or  shifting  process 
which  interposed  a  switch  between  the  stimulus  given  through 
the  eye  and  ear  and  the  first  instinctive  reaction.  The  same 
method  was  applied  to  thunder,  and  the  child  now  regards 
thunder  as  the  talk  of  the  clouds  telling  the  raindrops  to  fall. 
One  day  this  child  screamed  out  with  a  note  of  fear  in  his  voice 
when  his  older  sister,  growling  like  a  lion,  asked  him  to  hide 
under  his  bed-clothes  for  the  sake  of  play.  When  asked  why 
he  cried  out  and  why  he  refused  to  play,  he  replied  that  he  was 
afraid  to  go  under  the  bed-clothes  because  there  might  be  a 
lion  there.  ISPow,  for  hours  he  had  played  with  his  father, 
hiding  under  the  bed-clothes,  while  the  indulgent  parent  pre- 
tended to  seek  him  elsewhere,  and  he  would  continue  this  play 
without  let-up  on  innumerable  occasions  had  his  wish  been 
followed.  But  hearing  the  growl,  with  his  sister  impersonating 
a  lion,  meant  something  different  to  him.  The  next  day  when 
his  father  carried  him  upstairs  on  his  back,  he  said :  "I  am 
going  to  be  a  big  lion  and  you  are  the  baby  lion;  you  know 
lions  don't  talk  as  we  do,  they  growl,  but  they  understand  each 
other.  Now  I  am  going  to  growl  real  loud,  and  that  means  T 
love  you' ;  and  then  you'll  growl  back,  and  I'll  know  you  are 
saying  that  you  love  me.  Now,  when  I  am  going  upstairs,  if 
you  want  me  to  go  faster,  growl  louder  still,  and  I  will  know 
what  that  means."  As  a  result,  the  lion  play,  with  the  bed- 
clothes, is  a  source  of  pleasure  to  this  three  and  a  half  year  old 
boy. 

One  summer,  a  five  year  old  child, — a  little  girl  brought 
up  without  any  element  of  fear,  protected  from  stories  in  which 
death  was  mentioned,  a  child  to  whom  no  fairy  tales  were  read 


ENVIRONMENT  AND    HEREDITY  11 

because  it  was  seen  that  she  did  not  hke  them, — began,  several 
nights  in  succession,  on  going  to  bed,  to  call  repeatedly  for  her 
mother  or  nurse,  making  requests  of  all  sorts  as  an  excuse  to 
bring  them  into  her  presence.  She  was  questioned  carefully 
and  finally  informed  her  parents  that  several  little  girls  with 
whom  she  had  been  playing  recently,  for  the  first  time,  had 
spoken  about  kidnappers  and  kidnapping  and  had  been  warned 
by  their  paernts  not  to  go  out  of  th^  park  in  which  they  lived. 
Here  was  the  explanation  of  the  fear  of  this  five  year  old  child, 
one  who  at  the  age  of  nine  enjoys  reading  but  does  not  care 
for  Grimm's  fairy  tales.  Every  call  of  that  child  was  re- 
sponded to,  and  the  light  was  left  burning  in  her  room  or  in 
the  hall ;  and  with  the  simple  explanation  that  the  story  of  the 
kidnappers  was  an  old  tale  of  the  long  ago  and  had  nothing 
to  do  with  modern  days,  she  now  sleeps  without  a  light,  goes 
into  the  bathroom  at  any  hour  of  the  night,  and  presses  the 
electric  button  without  calling  any  one. 

It  should  be  generally  recognized  that  fear  tends  to  be- 
come fixed  in  a  child's  consciousness  and  thus  readily  becomes 
a  permanent  impression.  In  adult  life,  the  physician  sees  these 
fears  or  phobias  in  varying  degrees,  up  to  obsessions.  In  adult 
life  experience,  shocks, — such  as  frights,  worries,  disappoint- 
ments, financial  upsets,  loss  of  a  dear  one,  etc.. — may  cause 
psychic  injuries  which  produce  lasting  harm. 

With  a  child,  the  infectious  diseases  may  produce  a  tem- 
porary or  lasting  effect  on  any  one  or  more  of  the  glands  in 
the  endocrine  chain  and  thereafter  fear  may  be  more  readily 
aroused.  At  puberty,  when  the  ovarian  function  is  established, 
the  ovary, — the  interstitial  portion  of  which  has  been  active  up 
to  this  time. — evidences  the  entrance  of  the  glandular  portion 
into  more  or  less  rhythmical  play ;  so  to  speak,  a  new  endocrine 
has  been  introduced  into  the  circle  of  endocrines  engaged  in 
the  development  of  body  and  mind  and  associated  with  the 
play  of  the  instincts,  the  emotions,  and  the  psyche.  One  of 
the  normal  sex  functions  has  appeared,  and  from  this  time 
on  it  must  be  expected  that  its  action  and  the  action  of  the 
associated  glands  and  their  inter-relation  are  continually  more 


12  THE    ENDOCRINES 

and  more  centered  on  the  preservation  of  the  sex  organs,  and 
this  aside  from  any  consciousness  of  this  function  or  aside 
from  any  interpretations  or  views  which  the  child  may  acquire. 
This  akered  glandular  activity  must  of  necessity  exert  a  dif- 
fering trophic  stimulus  upon  the  brain  and  the  vegetative 
nervous  system,  with  a  consequently  to-be-expected  possible 
variation  both  on  the  instincts,  the  emotions,  and  the  psyche. 

And  the  reverse  of  this  action  is  also  to  be  expected.  At 
any  period  such  as  this,  the  life  of  the  individual,  his  books, 
plays,  teachers,  associates,  and  parents  may  markedly, — es- 
pecially in  the  more  sensitive, — rouse,  stimulate,  or  inhibit  the 
various  emotions  in  innumerable  ways  and  degrees.  During 
this  period,  as  well  as  later,  any  of  the  infections  or  the  infec- 
tious diseases  may  play  an  important  part,  especially  upon  the 
endocrines ;  and  this  period  of  adolescence  is  the  critical  period 
during  which  the  psychoses, — especially  dementia  praecox, — 
manifest  themselves. 

Influenza  undoubtedly  exerts  its  play  upon  the  endocrines, 
and  I  have  held  and  still  hold  that  the  mental  changes  result- 
ing therefrom,  which  are  of  course  evidenced  to  us  by  the 
psychic  alterations,  are  not  only  toxic  in  character  but  in  all 
probability  are  the  result  of  injuries  produced  in  the  various 
endocrines,  resulting  in  plus,  or  minus  or  dys. 

Happiness  or  the  pursuit  of  happiness  is  the  factor  of 
greatest  interest  in  our  existence.  The  real  purpose  for  each 
and  every  one  of  us  is  to  carry  on  the  physical  existence  of 
our  ancestors.  In  our  children,  fear  and  worry  are  the  great- 
est deterrents  to  happiness.  No  one  can  fully  appreciate  the 
horrible  and  lasting  effects  of  fear  unless  he  thoroughly  re- 
views the  events  of  his  own  life ;  for  everyone  knows  that  ex- 
perience is  the  best  teacher.  We  should  try  to  make  of  every 
parent  the  psychologist  who  can  teach  himself  more  by  a  re- 
view of  his  or  her  life  than  can  be  learned  from  all  the  books 
that  were  ever  written,  even  though  they  are  and  should  be  the 
greatest  aid  to  teaching.  And  here  let  me  say  that  if  books, 
plays,  biographies,  the  cinema,  history,  etc.,  were  used  to  ex- 
plain psychology,  and  if  they  were  properly  interpreted,  then 


ENVIRONMENT  AND   HEREDITY  13 

their  lessons  would  be  considered  the  essential  points  rather 
than  the  passing  interest  or  diversion  which  they  create,  how- 
ever wholesome  these  may  be.  Here  follows  an  experience  of 
a  friend  of  mine : 

"When  I  was  a  boy  we  had  a  cook  called  Katrina.  She 
was  most  devoted  to  six  children  in  her  care  and  attention ; 
and  her  subsequent  married  life  and  the  career  of  her  children 
has  been  a  matter  of  interest  to  all  of  us.  But  Katy  in  her 
desire  to  stop  the  nightly  pillow-fights  and  the  conversation 
indulged  in  after  we  were  tucked  in  bed,  informed  us  repeatedly 
of  the  dragons  and  little  dwarfs  which  she  would  call  to  her  aid 
to  punish  us  for  our  disobedience,  and  many  is  the  night  that 
I  have  lain  with  my  face  to  the  wall  unable  to  turn  around  be- 
cause Katy's  goblins  were  standing  there  with  hatpins  and 
sharp-pointed  instruments  biding  their  time  till  it  suited  them 
to  do  their  nefarious  work.  My  childhood  dreams  were  along 
lines  of  fear.  Only  one  who  has  gone  through  such  experi- 
ences can  appreciate  the  possibility  of  the  play  of  fears  on  the 
child's  mind  and  of  all  this  and  with  all  her  care  and  devotion, 
my  mother  knew  nothing  about  it. 

"Yet  very  early  in  my  life  my  mother  spoke  to  all  her  chil- 
dren concerning  what  she  termed  self-abuse.  She  warned  us  of 
the  various  things  we  might  see  or  be  told,  of  the  false  im- 
pressions that  might  be  created,  and  informed  us  that  it  was 
totally  within  our  power  to  be  perfectly  clean  and  sweet  and 
that  in  every  way  we  would  be  the  better  in  guarding  our- 
selves. She  said  that  four-footed  animals  had  their  heads  so 
placed  that  they  looked  to  the  ground,  for  that  was  the  source 
from  which  they  obtained  their  food.  God  had  put  man  on 
two  legs  so  that  he  could  look  forward  or  backward  mostly 
forward,  but  that  the  main  purpose  was  to  enable  him  to  hold 
his  head  high  and  to  look  upward  where  dwelt  the  Almighty 
who  created  and  governed  the  world.  She  said  that  for  this 
reason  we  should  not  look  downward,  so  far  as  our  persons 
were  concerned,  nor  should  our  thoughts  or  actions  turn  in 
that  direction." 

"I  remember  when  at  high  school,  the  principal  walking 


14  THE    ENDOCRINES 

down  the  aisle  tov/ard  me  one  day  and  saying  to  me  and  to  my 
brother  who  sat  at  the  next  desk,  'How  is  it  that  you  boys  never 
sit  with  your  legs  crossed,  never  keep  your  hands  in  your 
pockets,  and  never  touch  or  play  with  yourselves?'  And  I 
remember  his  look  of  astonishment  when  I  answered,  'Why. 
mother  told  us  all  about  it  long,  long  ago.'  He  walked  to  his 
desk,  called  the  schoolroom  of  boys  to  order  and  spoke  on  this 
question  for  several  minutes." 

Now  this  shows  a  certain  path  of  obligation  on  the  part 
of  parents  or  teachers,  for  we  recognize  the  fact  that  the  first 
impression  is  the  most  marked  and  lasting,  and  subsequent  er- 
roneous, false  or  abnormal  statements  or  teachings  as  they 
come  from  playmates  of  their  own  age  or  from  older  children 
then  have  to  battle  with  what  has  been  instilled  in  a  normal, 
wholesome  fashion. 

Early  Habits 

I  presume  that  one  who  remembers  his  boyhood  days 
and  his  school  companions  knows  the  hazy,  indefinite  and  pe- 
culiar notions  which  are  circulated  concerning  the  sex  or- 
gans,— receiving  from  some  minds  close  attention  and  imi- 
tation and  from  other  minds,  especially  if  they  have  been  well 
trained  and  warned  at  home,  receiving  no  consideration  what- 
ever. Without  experience  of  this  sort,  I  think  the  average 
individual  grows  up  with  a  rather  indefinite  notion  of  what 
these  practices  are,  how  commonly  they  are  followed  and  how 
they  are  spread. 

We  hear  much  of  the  bad  effects  and  the  evil  meaning  of 
thumb-sucking  In  children.  It  is  an  extremely  interesting  ob- 
servation that  almost  immediately  after  birth  the  average  baby 
gives  true  sucking  motion  with  its  lips,  and  very  promptly  the 
fingers  enter  its  mouth.  Hunger  is  satisfied  by  the  suckling 
tendency  of  the  child;  suckling  is  one  of  the  earliest  actions 
which  the  child  discloses.  At  this  time  at  least  we  can  scarcely 
talk  of  its  being  due  to  sex  stimulation.  To  turn  a  continuation 
of  this  earliest  manifestation  into  evidence  of  onanism  in  an 


ENVIRONMENT  AND   HEREDITY  15 

infant,  as  would  the  system  of  Freud,  seems  quite  out  of  keep- 
ing with  what  appears  to  be  the  true  state  of  affairs. 

All  mucous  membranes  are  sensitive  to  the  pleasurable, 
and  the  disagreeable  or  painful.  So  are  all  the  senses.  Every- 
one may  be  rubbed  the  right  or  wrong  way,  everyone  has  a . 
tender  or  sore  spot.  We  might  as  well  call  a  liking  for  candy 
and  sweets  or  a  fondness  for  certain  foods,  because  pleasur- 
able, evidences  of  a  sex  trend.  I  would  call  a  craving  for 
sweets  a  demand  exercised  by  some  metabolic  condition,  with 
some  endocrine  urge  at  the  back  of  it.  A  craving  for  alcohol 
is  an  excessive  urge  to  satisfy  immediately  a  need  which  may 
in  a  more  wholesome  manner,  though  much  more  slowly,  be 
satisfied  in  many  cases  by  sweets  or  other  foods. 

"Every  child  is  an  egoist  and  a  sensualist  during  a  period 
before  clear  thought  begins  and  verbal  language  is  used.  Every 
child  occupies  himself  in  dealing  with  a  body  of  sensations, 
some  of  which  he  finds  strangely  pleasurable  and  longs  to  re- 
produce." (Putnam.)  And  the  same  holds  true  all  through 
life. 

If  we  study  the  primitive  instincts  and  emotions  we  note 
that  they  are  of  different  and  varying  degrees  of  intensity  as- 
sembled in  varying  proportions  and  interrelations  just  as  we 
might  expect  from  the  chromosomes  which  carry  on  the  other 
inherited  characteristics.  If,  in  addition  to  these  innumerable 
possible  variations  in  instincts  and  emotions,  we  take  into 
consideration  the  influence  of  pluriglands  and  pluriglandular 
changes,  we  must  necessarily  picture  to  ourselves  the  existence 
(as  is  the  case)  of  a  tremendous  variety  of  personalities.  Since 
our  instincts,  emotions,  mental  and  psychic  states  are  stimu- 
lated, inhibited,  altered  and  complicated  by  endocrine  action, 
we  may  understand  that,  by  thinking  of  the  endocrines  as  a 
stimulus  and  the  emotions  and  the  psychic  factors  as  the  end 
result,  the  recall  or  the  awakening  of  any  experience  may  take 
place  without  the  element  of  volition,  as  in  dreams,  habits,  etc. 

The  neurologist  and  the  alienist  are  of  necessity  deeply 
concerned  with  psychology.     We  have  the  extensive  work  of 


16  THE    ENDOCRINES 

the  Freudians  which,  however,  takes  no  note  of  the  associated 
and  innumerably  varied  endocrine  stimulations  and  activities 
in  different  persons.  The  principle  is  that  suppression  of  sex 
impulses  constitute  the  injurious  factors.  But  why  do  they 
result  injuriously  in  some  and  not  in  others?  It  would  not  be 
true  to  say  that  because  we  find  these  changes  in  certain  beings, 
that  others  who  do  not  suffer  in  the  same  manner  may  not  have 
had  the  same  total  of  experiences.  If  they  have  had  these  same 
experiences  why  are  they  free  of  the  symptoms  belonging  to 
the  Freudian  complex?  Life  from  the  earliest  moment  is  a 
series  of  reactions  to  stimuli  acting  through  the  senses.  These 
reactions  are  related  to  instincts  and  emotions.  Action  is  the 
result  of  sensation  or  irritation  or  emotion.  We  cannot  sup- 
press an  emotion,  though  we  may  and  all  the  time  do  control 
the  impulse  prompted  by  an  instinct  or  emotion.  So  we  are 
all  the  time  suppressing  impulses  and  desires  and  thousands 
of  those  who  do  not  are  to  be  found  in  our  prisons. 

Repression  of  an  act  or  function  associated  with  or  sup- 
posed to  complete  an  emotion  implies  that  some  endocrine  out- 
pouring, instead  of  being  used  in  the  completion  of  the  act  and 
in  supplying  the  stimulus  or  energy  associated  with  that  act, 
is  exerting  its  action  elsewhere  and  in  other  channels  so  that 
internal  combustion  is  going  on  instead  of  an  explosion.  This, 
of  course,  accounts  for  innumerable  variations  in  internal  func- 
tion, mental  action  and  psychic  effect. 

And  so  any  bad  habit,  such  as  onanism,  not  only  disturbs 
internal  secretory  relations,  but,  if  carried  too  far,  dissociates 
from  itself  other  normal,  mental,  physical  and  psychic  activi- 
ties, and  removes  them  from  the  field  of  desire  and  interest. 
Hence  onanism  according  to  the  effect  it  produces,  according 
to  the  mental  and  psychic  constitution  of  the  individual  and 
according  to  the  interpretation  which  the  individual  places  on 
the  habit,  is  for  these  reasons  and  along  these  lines,  in  some 
cases  possibly  harmless,  in  others  harmful  and  in  many  cases 
most  injurious. 

If  during  certain  psysiological  periods  of  development 
attention  is  unconsciously  attracted  to  the  sex  organs,  this  may 


ENVIRONMENT  AND  HEREDITY  17 

in  a  way  be  considered  a  natural  trend.  To  permit  a  child  or 
adult  to  center  continued  attention  by  touch,  manipulation  and 
thought  in  these  channels  stimulates  and  rouses  the  associated 
emotions,  sensations  and  endocrines  and  may  make  that  path 
unusually  sensitive.  If  one  is  frightened  by  being  told  that 
this  habit  leads  to  mental  upset  and  degeneracy,  the  psychic 
effect,  if  the  habit  be  continued,  may  be  very  bad.  If  the  habit 
becomes  pronounced,  it  may  and  often  does  have  a  bad  physical 
and  psychic  influence  leading  more  readily  to  other  processes 
and  relations,  all  of  which  may  readily  be  responsible  for 
neuroses  of  various  sorts. 

Unusual  fondness  or  devotion  to  any  pleasure  or  amuse- 
ment may  lessen  the  desire  for  other  pleasures  or  even  for 
one's  vocation  or  duties.  I  am  told  that  many  years  ago  in 
England  business  contracts  between  partners  contained  a  clause 
that  neither  should  play  golf  except  on  holidays.  So  it  is  with 
habits  and  processes  of  mind.  Constant  repetition  brings  in 
associated  ideas  or  suggested  by-views  which  extend  the  range 
of  the  original  work,  thought  or  idea.  Increased  concentra- 
tion in  one  thing  may  result  eventually  in  a  dissociation  from 
other  spheres,  and  according  to  degree  may  be  wholesome  or 
may  interfere  with  the  sense  of  proportion  and  relation.  Hence 
the  value  of  diversions,  avocations  and  hobbies.  Hence  con- 
tinued worry,  grief,  hatred,  animosity,  suspicion,  regret  are 
concentrations  which  in  addition  to  the  endocrine  activities  as- 
sociated therewith,  are  often  carried  to  the  point  where  the 
sense  of  proportion  is  lost  and  the  diversions  of  other  thoughts 
and  pleasant  emotions  are  totally  neglected  or  rendered  impos- 
sible. To  whatever  degree  concentration,  whether  it  be  pleas- 
urable, serious,  scientific  or  speculative,  is  carried  too  far,  the 
mechanism  of  the  psycho-physical  nature  is  put  to  continued 
use  and  to  great  strain.  However  much  it  may  be  well-borne 
at  first,  it  lends  itself  either  to  the  exhaustion  of  that  mechanism 
or  to  such  high  development  of  it  that  its  activities  are  ab- 
normal and  its  reactions  oversensitive  and  exaggerated. 

The  immediate  surroundings  in  which  a  boy  or  girl  lives 
during  sexual  development  all  have  an  influence.     The  de- 


18  THE    ENDOCRINES 

gree  and  character  of  the  influence  exerted  from  the  genitalia 
depend  on  the  resistance  of  the  nervous  system,  or  on  the  tem- 
perament, hereditary  constitution,  education,  and  training. 

"Too  early  entrance  into  social  life,  attendance  at  theatre, 
and  the  reading  of  general  literature  may  have  a  bad  sexual 
effect.  All  these,  added  to  the  knowledge  of  development  and 
the  establishment  of  the  menstrual  function,  and  the  character 
of  the  child's  associations,  determines  the  degree  to  which  the 
hazy  and  indefinite  "sexual  instinct"  follows  a  normal  or  ex- 
citable course.  Psychologic  reaction  to  the  "sexual  instinct" 
at  puberty  evidences  itself  in  many  ways,  all  of  which  repre- 
sent the  need  of  expressing  objectively  the  newly  developed 
inner  feeling.  Religion  and  poetry  are  often  the  fields  in  which 
these  longings  are  expressed.  Young  girls  at  puberty  often 
give  themselves  up  to  enthusiastic  admiration  and  adoration  of 
ideals  or  concrete  factors.  The  mind  of  adolescent  girls  is 
often  occupied  with  thoughts  which  concern  the  objects  of  their 
affection.  Exciting  or  immodest  literature  and  plays  and  the 
influence  of  sophisticated  associates  may  start  the  indefinite 
hazy,  sexual  inclinations  into  a  flame."     (Kisch.) 

Our  universities  incline  to  athletic  sport  for  boys  and 
girls.  Anyone  with  a  real  mind  must  know  that  our  educa- 
tors realize  that  it  is  not  only  healthful  but  that  it  diverts  the 
mind  from  the  sphere  of  sex  during  all  these  important  years. 
Inasmuch  as  we  are  speaking  of  the  wholesome  effect  of  ath- 
letics and  diversions  of  a  wholesome  type,  let  us  at  this  point 
show  the  ability  of  an  individual  to  switch  an  emotion  into  the 
pleasurable  with  the  aid  of  the  psyche  and  the  added  element 
of  interest.  Imagine  yourself  in  the  Yale  Bowl  watching  a 
contest  between  Yale  and  Harvard.  Harvard  makes  a  touch- 
down. Immediately  thirty  thousand  wild,  enthusiastic  men 
and  women,  filled  with  enthusiasm,  are  contrasted  with  thirty 
thousand  who  sit  quiet  and  depressed.  Yet  both  have  viewed 
the  same  event.  A  few  minutes  afterwards  Yale  makes  a 
touchdown  and  the  thirty  thousand  depressed  ones  act  like 
howling  dervishes,  while  the  others  are,  in  turn,  quiet.  And 
so  it  is  possible  to  switch  events,  occurrences,  irritations,  into 


ENVIRONMENT   AND   HEREDITY  19 

pleasurable  or  less  annoying  emotions  by  what  we  call  diver-f 
sions.  And  this  ability  is  greatly  enhanced  if  we  teach  an 
adolescent  or  an  adult  that  a  wholesome  or  injurious,  psychic, 
physical  or  endocrine  state  is  associated  with  habits  according 
as  these  are  good  or  bad. 

Pleasant  events,  joyful  experiences,  strong  emotions,  men- 
tal shocks,  worry,  frights,  etc.,  may  make  such  a  deep  impres- 
sion on  the  cerebral  film  that  the  mind  is  unable  to  shift  or 
switch  thoughts  into  other  channels.  This  may  be  true  of  good 
or  pleasing  impressions  as  well  as  of  bad  ones.  The  latter, 
of  course,  are  injurious  and  we  often  say  "it  makes  or  has 
made  a  good  impression,"  "it  makes  or  has  made  a  bad  im- 
pression." 

Voluntary  recalls  of  pleasant  events  constitute  the  most 
enjoyable  and  wholesome  processes  of  which  the  mind  is 
capable.  Recalls  occur  frequently  enough  in  dreams  at  fre- 
quent or  infrequent  intervals  for  short  periods  or  for  years. 
The  innumerable  factors  forgotten  and  remembered  are  the 
prompting  influences  which  lead  to  recalls  in  the  waking  state, 
in  the  dreamy  waking  state,  and  in  dreams. 

When  a  person  recounts  the  story  of  any  experiences,  we 
simply  have  to  note  how  his  language,  inflection,  behavior, 
countenance,  attitude,  etc.,  change  in  accord  with  the  recall  of 
the  various  emotions  belonging  to  that  experience. 

The  face  of  a  child  when  listening  intently  to  a  story, 
his  expression,  his  color,  his  attitude,  show  simply  the  ex- 
pression of  the  emotions  roused  through  the  sense  of  hearing. 
In  our  reading,  in  our  observation,  in  the  theatres,  at  the 
cinema,  we  are  played  upon,  our  emotions  are  played  upon, 
our  instincts  are  roused  or  repressed  within  the  range  of  a  few 
hours, — so  we  say,  'that  we  have  "run  the  entire  gamut  of  the 
emotions."  And  since  all  this  involves  endocrine  activities 
a  play  or  a  cinema  leaves  one  tired  and  worn,  if  certain  emo- 
tions have  been  roused;  pleased,  with  a  feeling  of  well-being, 
if  other  emotions  have  been  aroused.  So  that  however  one 
may  appreciate  good  acting  and  strong  plays,  the  tastes  of  most 
people, — especially  when  tired, — lean  toward  the  pleasant  and 


20  THE    ENDOCRINES 

laughter  producing  type.  Hence  we  hear  the  critic  say :  "This 
is  a  play  for  the  tired  business  man." 

Pseudo  emotions  of  pity  and  sympathy  may  be  readily 
aroused ;  hence  pleas,  events,  or  problems  concerned  with  chil- 
dren, especially  affect  the  parental  instinct  and  make  the 
strongest  appeal.  Thus  an  appeal  for  charity  is  more  readily 
responded  to  if  the  welfare  of  the  expectant  mother  or  the 
health  and  welfare  of  childern  are  the  pleas  used  as  channels 
of  approach. 

The  effect  of  early' impressions,  the  influence  of  one  of 
the  diseases  of  childhood  is  well  recorded  by  Henry  Adams  in 
"The  Education  of  Henry  Adams." 

"Of  all  that  was  being  done  to  complicate  his  education, 
he  knew  only  the  color  of  yellow.  He  first  found  himself  sit- 
ting on  a  yellow  kitchen  floor  in  strong  sunlight.  He  was  three 
years  old  when  he  took  this  earliest  step  in  education ;  a  lesson 
of  color.  The  second  followed  soon;  a  lesson  of  taste.  On 
December  3,  1841,  he  developed  scarlet  fever.  For  several 
days  he  was  as  good  as  dead,  reviving  only  under  the  careful 
nursing  of  his  family.  When  he  began  to  recover  strength, 
about  January  1,  1842,  his  hunger  must  have  been  stronger 
than  any  other  pleasure  or  pain,  for  while  in  after  life  he  re- 
tained not  the  faintest  recollection  of  his  illness,  he  remem- 
bered quite  clearly  his  aunt  entering  the  sick-room  bearing  in 
her  hand  a  saucer  with  a  baked  apple. 

"As  a  means  of  variation  from  a  normal  type,  sickness  in 
childhood  ought  to  have  a  certain  value  not  to  be  classed  under 
any  fitness  or  unfitness  of  natural  selection;  and  especially 
scarlet  fever  affected  boys  seriously,  both  physically  and  in 
character,  though  they  might  through  life  puzzle  themselves  to 
decide  whether  it  had  fitted  or  unfitted  them  for  success;  but 
this  fever  of  Henry  Adams  took  greater  and  greater  im- 
portance in  his  eyes,  from  the  point  of  view  of  education,  the 
longer  he  lived.  At  first  the  effect  was  physical.  He  fell  be- 
hind his  brothers  two  or  three  inches  in  height,  and  propor- 
tionally in  bone  and  weight.  His  character  and  processes  of 
mind  seemed  to  share  in  this  fining-down  process  of  scale.   He 


ENVIRONMENT  AND   HEREDITY  21 

was  not  good  in  a  fight,  and  his  nerves  were  more  delicate  than 
boys'  nerves  ought  to  be.  He  exaggerated  these  weaknesses  as 
he  grew  older.  The  habit  of  doubt ;  of  distrusting  his  own  judg- 
ment and  of  totally  rejecting  the  judgment  of  the  world;  the 
tendency  to  regard  every  question  as  open;  the  hesitation  to 
act  except  as  a  choice  of  evils;  the  shirking  of  responsibility; 
the  love  of  line,  form,  quality ;  the  horror  of  ennui ;  the  passion 
for  companionship  and  the  antipathy  to  society — all  these  are 
well  known  qualities  of  New  England  character,  in  no  way 
peculiar  to  individuals,  but  in  this  instance  they  seemed  to  be 
stimulated  by  the  fever,  and  Henry  Adams  could  never  make 
up  his  mind  whether,  on  the  whole,  the  change  of  character 
was  morbid  or  healthy,  good  or  bad,  for  this  purpose.  His 
brothers  were  the  type;  he  was  the  variation," 

The  Stork 

One  of  the  greatest  problems  which  confront  parents  is 
the  satisfaction  of  the  curiosity  manifested  by  children.  They 
pass  their  early  lives  enjoying  the  delightful  relationship  with 
Santa  Claus  until  information  imparted  from  different  sources 
deprives  them,  much  to  their  regret,  of  this  most  enjoyable 
experience  of  their  younger  years.  It  has  done  them  the 
greatest  of  good  and  inculcates,  perhaps  without  our  realizing 
it,  the  principles  of  good  will,  generosity,  kindness  and  the 
love  which  kindly  old  faced,  gray  haired,  bearded,  smiling 
Santa  has  for  little  chilrden. 

The  little  ones  say  their  prayers  and  are  carried  into  a 
state  of  trust  and  reliance  in  the  omnipotence,  kindliness  and 
love  vested  in  a  supreme  being.  Thus  we  explain  to  the  im- 
mature mind  many  of  the  wonders  which  at  that  age  we  could 
not  explain  in  detail  in  language  sufficiently  simple  to  be 
grasped  with  understanding. 

The  stork  and  the  doctor  bring  baby  sisters  and  baby 
brothers  and  the  little  ones  pray  and  ask  for  a  brother  or 
sister  when  the  knowledge  is  ours  that  one  is  on  the  way. 

But  there  comes  a  time  when  the  mind  and  the  curiosity, 
coupled  with  what  children  see,  hear,  read,  and  overhear,  seek 


22  THE    ENDOCRINES 

for  and  demand  explanations  which  appeal  more  to  their  reason 
and  which,  if  told  to  them  in  the  proper  form,  not  only  satis- 
fies their  curiosity,  not  only  prevents  them  from  receiving  such 
information  (often  misinformation)  in  ways  which  are  in- 
jurious, but  here  follows  the  most  important  point  of  all. 

Children  should  not  be  led  to  believe  that  inquiry  along 
these  lines  is  anything  but  natural,  and  the  more  ready  and 
prompt  is  the  response,  the  more  it  is  given  as  if  the  question 
were  a  perfectly  normal  and  proper  one,  the  more  is  the  idea 
of  the  sex  complication  laid  aside  for  the  moment.  Children 
know  that  cows  have  calves,  that  dogs  have  puppies,  that 
chickens  have  chicks,  that  birds  lay  eggs  and  that  married 
folks  have  children.  It  never  or  rarely  enters  their  minds  as 
to  what  makes  a  chicken  develop  in  eggs,  except  the  fact  that 
a  hen  sitting  on  them,  keeping  them  warm,  allows  the  little 
chick,  after  a  definite  period,  to  peck  its  way  out  of  the  shell. 
Now  a  cow,  when  it  has  a  calf,  lays  an  egg,  but  if  a  cow  were 
to  sit  on  such  an  egg  the  shell  would  break  and  it  might  crush 
the  little  calf.  Besides  the  cow  has  to  eat  its  food,  stand  under 
a  shady  tree  in  warm  weather,  wander  about  the  pasture  and 
give  its  milk.  Therefore,  nature  arranges  it  so  that  when  the 
cow  lays  its  egg  the  little  calf  is  ready  for  immediate  hatching. 

Children  know  about  the  cross  breed  of  dogs  and  it  cer- 
tainly hurts  no  little  boy  to  have  his  father  talk  in  a  perfectly 
natural  manner  about  the  breeding  of  horses  and  the  improve- 
ment in  them,  in  cattle,  in  sheep,  etc.,  according  to  the  well 
known  principles  practiced  by  breeders. 

I  took  a  boy  ten  years  of  age  to  a  sporting  goods  store 
to  buy  a  collar  for  his  latest  possession,  a  well  bred  Boston 
Bull,  to  whom  he  was  greatly  devoted  and  whom  he  carried 
about  as  a  mother  carries  a  baby.  On  the  counter  lay  a  pile 
of  pamphlets  dealing  with  the  diseases  of  dogs.  He  asked  me 
if  he  might  have  one,  and  I  said,  "Yes,  of  course,"  after 
glancing  over  it  casually.  Two  days  afterwards  he  showed 
me  the  pamphlet,  and  on  one  page  was  a  picture  of  forceps  used 
in  the  delivery  of  dogs.  I  was  startled  for  a  moment  and  said, 
"Why,  of  course,"  if  the  egg  won't  come  out  of  its  own  ac- 


ENVIRONMENT  AND   HEREDITY  23 

cord,  the  veterinary  takes  the  httle  puppy  out  of  the  shell  him- 
self. Didn't  you  know  that?"  This  was  the  only  thing  to  do 
and  was  the  proper  thing  to  do,  though  had  I  known  I  might 
not  have  put  that  pamphlet  in  his  hands  at  that  time. 

A  little  girl  of  nine  years,  of  very  active  mind,  in  many 
of  whose  books  many  babies  had  been  born,  said  one  day, 
"How  do  babies  really  come?  Why  does  the  stork  or  the 
doctor  bring  it  so  late  in  the  morning  instead  of  in  the  day 
time,  when  it  is  so  much  more  convenient?"  It  would  have 
been  perhaps  a  more  comfortable  feeling  to  have  been  able 
to  wait  until  this  child  was  older,  but  in  the  meantime  curios- 
ity, plus  information  given.  Heaven  knows  in  what  fashion, 
would  certainly  have  produced  an  impression  far  different  from 
those  the  parents  desire,  and  so  I  said,  "You  know  a  hen  lays 
an  egg,  and  keeps  it  warm  till  the  chick  comes  out.  You  know 
a  cow  lays  an  egg,  but  the  little  calf  comes  right  out  of  the 
egg  as  soon  as  it  is  laid.  It  is  just  the  same  way  with  ,any 
mother;  it's  all  just  in  the  laying  of  an  egg,  and  the  larger  the 
little  ones,  the  greater  the  danger  of  hurting  them,  if  the 
mothers  were  to  sit  on  the  eggs.  The  sooner  they  come  out  of 
the  shell  the  better.  A  seed  is  really  nothing  but  a  little  egg; 
the  only  thing  is  that  a  tree  can't  sit  on  it  and  keep  it  warm," 
and  before  I  had  a  chance  to  say  another  word  the  child  said, 
"Yes,  that's  why  its  put  into  the  ground,  to  keep  it  warm,  and 
then  the  sun  shines  on  it,  and  that  keeps  it  warm  too,"  and  I 
said,  "The  sun  keeps  us  all  warm  and  gives  us  life,  and  makes 
the  grass  grow,  and  makes  the  leaves  green,  and  is  one  of  the 
most  important  things  which  God  has  given  to  make  this 
world  what  it  is." 

That  child's  curiosity  has  been  satisfied;  a  wholesome 
explanation  has  been  given ;  one  which  is  perfectly  true  and 
correct,  and  no  suggestion  has  been  put  into  that  child's  mind 
that  the  question  involves  anything  which  she  has  not  a  right 
to  know  or  to  understand.  She  was  told  further  that  this  was 
a  sweet  and  very  personal  communication  between  any  parent 
and  any  child,  and  that  it  was  not  to  be  communicated  to  any 
other  child,  as  every  parent  wanted  the  pleasure  of  telling  this 


24  THE    ENDOCRINES 

to  her  or  his  own  children,  nor  was  any  other  explanation  than 
the  one  given  above  the  correct  one,  and  that  any  future  in- 
formation on  this  question  would  be  gladly  and  readily  given 
whenever  she  desired. 

It  Pays 

In  teaching  moral  standards,  making  an  appeal  to  the 
sense  of  honor  or  dignity  or  loyalty,  etc.,  the  ethical  point  of 
view  can  be  strengthened  by  proving  likewise  that  "it  pays." 
If  it  is  better  to  be  honorable  and  honest  and  just  and  truth- 
ful, it  must  be  shown  that  it  is  to  the  advantage  of  the  indi- 
vidual in  his.  relations  with  men,  and  that  it  contributes  to  the 
one  who  practices  these  principles  a  sense  of  happiness,  well- 
being,  and  self-respect.  If  a  girl  be  taught  that  each  time 
that  she  becomes  angry  there  is  an  associated  endocrine  re- 
action, which  exhausts  her  reserve,  makes  the  next  attack  of 
anger  more  readily  roused  and  that  the  physical  changes  re- 
sulting therefrom  are  harmful,  the  impression  made  by  the 
advice  is  increased.  If  girls  are  taught  that  every  wholesome, 
pleasant  emotion  is  associated  with  an  associated  organic  and 
endocrine  action  or  reaction  with  benefit  to  the  body  functions 
as  well  as  to  the  mental  state,  the  advice  to  smile,  to  be  cheer- 
ful, to  be  optimistic,  to  look  on  the  bright  side  of  things,  has 
more  than  an  ethical  significance. 

If  a  man,  with  wife  and  children,  develops  an  incipient 
tuberculosis  and  if  at  the  expense  of  a  certain  amount  of 
money  he  is  sent  to  a  sanitarium  to  recover  his  health  and  if 
at  the  same  time  his  wife  and  family  are  given  financial  aid 
to  keep  them  from  want  and  suffering,  that  man  comes  back 
at  the  end  of  a  year  healthy  and  well  and  able  for  the  next  ten 
or  twenty  years  to  support  his  wife  and  children. 

Aside  from  the  glorious  results  to  the  donor  and  to  the 
afflicted  which  results  from  such  beneficent  action,  "it  pays." 
If  this  had  not  been  done  and  the  man  had  been  allowed  to 
develop  a  more  severe  and  probably  incurable  form  of  pul- 
monary tuberculosis,  his  earning  power,  his  ability  to  care 
foi  his  wife  and  children,  would  be  at  an  end  and  he  himself 


ENVIRONMENT  AND    HEREDITY  25 

would  be  a  liability  to  the  community  and  not  an  asset;  and 
the  future  of  that  wife  and  children  would  be  markedly  and 
injuriously  affected.  Whether  the  motive  which  prompts  such 
beneficent  action  is  kindly,  charitable  and  generous  or  whether 
it  is  based  on  an  appreciation  of  its  utility,  the  desirable  end 
result  is  obtained. 

If  a  young  person  is  given  advice  as  to  morals,  habits 
and  standards  based  on  any  abstract  ground  of  morality,  ethics 
or  religion,  it  is  certainly  advisable  by  warning  against  the 
dangers  to  one's  physical  self,  to  prove  the  value  of  morals  by  a 
realization  that  "it  pays."  If  we  explain  the  injurious  physical 
effects  of  onanism,  if  we  teach  the  injurious  physical  and 
psychic  results  of  abnormal  sexual  practices,  if  we  portray  the 
dangers  and  frequent  lasting  injurious  effects  of  a  gonorrhoea! 
infection,  if  we  teach  that  syphilis  affects  not  only  the  body  but 
the  nervous  system,  that  its  destructive  influence  may  only  be 
evidenced  in  after  years,  often  in  an  incurable  form,  that  one 
may  readily  without  knowing  it  convey  the  infection  to  his 
^wife  and  through  her  to  some  or  all  of  his  children,  we  cer- 
tainly enforce  the  effects  of  moral  teaching  by  the  knowledge 
that  "it  pays"  to  protect  one's  self  and  one's  future  and  the 
future  of  those  who  some  day  may  be  our  dearest  possessions. 
If  the  sufficiently  ripe  mind  is  informed  that  gonorrhoea  is 
one  of  the  most  frequent  causes  of  sterility  in  the  male  or 
female,  we  are  appealing  not  only  to  the  instinct  of  self-preser- 
vation, but  to  the  paternal  and  maternal  instinct  which  can- 
not be  roused  too  earl}^  in  a  wdiolesome  fashion.  The  maternal 
instinct  must  be  distinguished  from  the  instinct  of  sex  or  the 
sex  urge.  We  give  our  little  girls  and  boys  different  forms 
of  plays.  The  boy  has  his  soldiers  and  guns,  his  drums  and 
tools,  his  Indian  suit  and  his  soldier  suit,  his  outdoor  sports 
and  plays,  all  of  which  are  supposed  to  develop  his  normal  in- 
stincts supposedly  manly  in  type  as  he  grows  older.  And  so 
we  encourage  in  our  boys  a  fondness  for  athletics,  an  enjoy- 
ment in  football  and  physical  contests ;  we  inculcate  a  love  for 
the  pleasures  of  camping,  hunting  and  fishing.  Not  onlv  do 
these  develop  the  instincts  which  are  normal  and  manly  but  they 


26  THE    ENDOCRINES 

develop  the  body,  stimulate  growth,  and  overshadow,  cover 
up  and  anesthetize,  so  to  speak,  the  instincts  of  sex  as  they  ap- 
pear during  the  years  before  adolescence  in  varying  degrees 
according  to  development  and  the  stimulation  excited  through 
the  various  senses. 

Educators  recognize  the  importance  of  these  factors  and 
it  is  only  the  unthinking  mind  that  complains  of  too  much  ath- 
letics in  our  universities,  for  after  all  during  those  three  or 
four  years  the  young  man  is  developing  physically,  acquiring 
knowledge,  becoming  sufficiently  old  to  more  readily  realize 
the  channels  in  which  he  can  best  exercise  his  ability  in  the 
choice  of  his  activities,  but  he  also  profits  by  the  example  of 
his  instructors,  absorbs  or  is  influenced  by  admiration  of  their 
qualities,  is  improved  by  contact  with  his  teachers,  learns  to 
mingle  with  others,  learns  the  principles  of  "give  and  take"  in 
the  intercourse  between  men  and  acquires  self-confidence  and 
a  respect  for  culture  and  education  which,  if  it  is  not  an  exag- 
gerated concept,  gives  him  a  backbone  throughout  life. 

Our  little  girls  are  given  their  dolls,  their  dresses,  their 
cooking  utensils,  their  play,  their  dress,  their  teachings.  Their 
observation  of  the  differing  responsibilities  of  men  and  women 
develops  instincts  along  different  lines,  the  original  notion 
being  along  lines  tending  to  the  acqurinig  of  the  domestic 
virtues  and  a  preparation  for  the  understanding  and  practice 
of  the  maternal  instincts  and  virtues. 

'  Whatever  we  may  say  of  the  advantages  of  training  girls 
to  be  self-reliant  and  to  take  greater  interest  in  the  activities 
of  life  formerly  belonging  almost  exclusively  to  men,  none  of 
these  factors  interfere  with  the  development  of  the  more  essen- 
tial, attractive  and  charming  qualities  so  much  appreciated  in 
mother,  wife,  sister  or  daughter. 

If  we  realize  that  children  are  plastic  material  to  be 
moulded  as  we  desire,  we  make  a  serious  mistake.  You  may 
mould  until  a  child  is  conscious  of  what  you  are  doing,  and 
then  it  reacts  to  these  stimuli  with  an  ego  of  its  own.  That  is 
the  time  to  stop  moulding  and  to  begin  educating.  And  it  is 
probably  better  to  begin  educating  long  before  this.     For  edu- 


ENVIRONMENT  AND   HEREDITY  27 

cation  means  to  bring  out.  Therefore,  it  means  to  stimulate, 
to  rouse,  to  bring  out,  and  to  give  practice  to  the  good  in- 
stincts ;  it  means  not  to  rouse,  not  to  stimulate,  but  to  over- 
shadow, cover  up  and  not  to  give  practice  to  the  instincts  which 
may  be  harmful  to  the  child  or  to  others.  As  different  chil- 
dren have  their  instincts  and  the  associated  emotions  within 
them  of  varying  degrees  of  intensity  and  in  varying  combina- 
tions, and  as  these  instincts  appear  at  different  ages,  increas- 
ing or  diminishing  in  intensity  according  to  physical  constitu- 
tion and  according  to  the  natural  development  of  the  various 
physical  functions,  the  girl's  knowledge  of  herself  must  not 
be  limited  to  the  explanation  of  physiological  phenomena  only. 

I  believe  as  soon  as  older  children  can  reason  and  under- 
stand, that  we  are  privileged  to  talk  with  them  about  their  in- 
stincts and  emotions,  to  explain  that  these  can  be  developed 
or  held  in  check  and  that  their  reactions  to  stimuli  may  be 
controlled  by  repeated  attempts  in  these  directions.  Then  the 
effect  of  our  training  would  be  greatly  increased.  Even  a  body 
of  soldiers  led  by  their  officers  on  a  hazardous  journey  is  much 
better  fitted  to  execute  the  desired  purpose  if  the  purpose  and 
objective  of  their  expedition  is  known  to  them. 

Why  should  we  not  study  a  child's  instincts  and  emo- 
tions, its  likes  and  dislikes,  its  attractions  and  aversions?  All 
these  things,  especially  as  they  grow  older,  are  their  per- 
sonal and  most  intimate  affairs.  It  is  they  who  are  ultimately 
concerned,  benefited  or  injured.  We  are  all  the  time,  perhaps 
without  realizing  it,  permitting  continued  appeals  to  their  in- 
stincts and  emotions.  They  get  it  through  books,  from  plays, 
from  the  cinema,  from  biographies,  from  contact  with  the 
world,  at  school,  in  the  papers  and  magazines.  Some  children 
and  some  adults  are  able  to  select  the  worthwhile  from  the 
pernicious.  Unfortunately,  however,  we  forget  that  even 
faults  and  weaknesses  and  vices  carry  their  propaganda  when 
made  attractive  by  charms  of  detail  or  exterior,  or  by  the 
result  attained. 

It  requires  even  a  wise  person  to  realize  that  "all  that  glit- 
ters is  not  gold,"  and  if  many  grownups  never  learn  this,  what 


28  THE    ENDOCRINES 

right  have  we  to  expect  that  children  and  the  younger  genera- 
tion should  see  the  truth  of  this  statement  ? 

We  bring  up  our  children  with  many  a  moral  proverb  or 
axiom;  we  send  them  to  school  and  to  college  where  they 
learn  much  of  the  abstract  principles  of  justice;  but  if  these 
teachings  such  as  "if  he  smite  thee  on  one  cheek,  turn  to  him 
the  other,"  and  the  abstract  principles  of  justice  are  not  tem- 
pered with  advice  as  to  self-protection  and  self-preservation; 
if  the  teachings  of  history  are  not  used  to  impress  youthful 
minds  with  the  facts  that  the  world  is  a  place  of  contest,  and 
that  civilization  has  often  forced  castor  oil  down  the  unwilling 
throats  of  the  uncivilzed  and  the  savage  to  his  final  better- 
ment, we  are  very  apt  to  be  responsible  for  the  development  of 
impractical  ideas  of  generosity,  justice,  and  equality  which  are 
as  likely  to  do  harm  as  if  we  were  to  go  to  the  opposite  ex- 
treme and  teach  nothing  on  these  subjects  at  all. 
,  In  the  education  of  children  and  the  young  and  in  the 
-whole  period  of  one's  life,  for  that  matter,  the  idea  is  to 
strengthen  the  good  instincts,  to  develop  them  and  to  bring 
them  out;  and  to  cover  up  and  bring  out  as  little  as  possible 
or  to  inhibit  the  baser  or  the  injurious  or  the  unworthy. 

And  since  ultimately  every  individual  life  is  more  or  less 
under  his  own  direction,  or  associated  with  a  partner,  or  in 
contact  with  varying  types  of  natures,  the  earlier  one  learns 
to  understand  his  instincts  and  emotions,  and  the  earlier  he 
understands  his  disposition  and  his  temperament,  the  better 
able  will  he  be  to  understand  the  "I"  in  character  even  though 
that  letter  does  not  appear  in  the  word. 

Some  children  have  the  instinct  of  subjection  so  marked 
that  their  instinct  of  self-assertion  must  be  encouraged  to  the 
greatest  possible  extent.  They  should  be  praised,  encouraged 
and  never  be  made  conscious  of  "bashfulness"  or  lack  of  initia- 
tive, or  lack  of  courage.  They  recognize  these  failings  with- 
out our  knowing  it,  and  it  is  better  that  we  should  not  let 
them  know  that  we  too  are  aware  of  it.  On  the  other  hand  the 
greatest  of  harm  can  come  if  the  instinct  of  self-assertion  is 
allowed  too  great  freedom  and  practice  along  lines  that  create 


ENVIRONMENT  AND   HEREDITY  29 

the  ego  in  too  exaggerated  a  form,  especially  in  the  matter  of 
pride,  sense  of  superiority,  the  over-estimation  of  the  meaning 
of  wealth  and  position.  Personal  pride,  pride  in  one's  accom- 
plishments, pride  in  matters  involving  dignity,  reputation, 
standing,  etc.,  are  all  along  normal  lines.  The  injurious  ef- 
fect of  over-exaggeration  of  the  instinct  of  self-assertion  is 
well  exemplified  in  Booth  Tarkington's  "The  Magnificent  Am- 
bersons." 

The  stimulation  of  the  best  instincts  and  the  rousing  of 
the  best  emotions  must  not  be  confused  with  over-indulgence 
or  with  the  exaggerated  development  of  the  self-assertive  in- 
stinct, since  the  latter  may  result  in  an  exaggerated  ego  with 
no  adequate  counter-balance  by  the  instinct  of  subjection.  I 
know  no  better  way  of  exemplifying  this  fault  than  by  calling 
attention  to  the  "Magnificent  Ambersons,"  written  by  that 
master  psychologist.  Booth  Tarkington.  Here  the  mother, 
whose  only  son  is  the  all-absorbing  object  of  her  great  ma- 
ternal instinct,  indulges  the  son  to  such  an  extent  that  his  brave 
and  courageous  characteristics  develop  him  in  a  "cock  o'  the 
walk."  As  a  result  of  his  subsequent  notions  and  her  yield- 
ing spirit,  and  her  misguided  adoration  of  her  son,  he  un- 
wittingly spoils  lier  life,  and  her  opportunity  for  real  hap- 
piness during  her  more  mature  years.  When  he  subsequently 
loses  her  and  falls  to  earth,  is  left  penniless,  practically  friend- 
less and  with  responsibilities  on  his  hands,  he  loses  his  ar- 
rogance and  his  exaggerated  pride,  settles  down  to  work  with 
most  praiseworthy  energy  and  determination.  He  soon  realizes 
his  previous  shortcomings  and  proves  himself  to  be  a  real 
man  through  the  exercise  of  the  very  instincts  and  powers 
which  were  distinctly  recognizable  in  him  as  a  boy,  and  which 
at  that  time  could  have  been  properly  seasoned  by  restraint 
and  a  sense  of  proper  relation  to  his  environment  and  to  the 
world. 

Discipline 

As  much  as  we  hope  that  our  children  may  learn  from 
us  just  so  much  and  more  may  we  learn  from  them.     Punish- 


30  THE    ENDOCRINES 

ment  of  whatever  sort  has  its  excuse  only  because  it  makes  an 
impression  in  the  teaching  of  a  lesson.  My  little  boy,  when 
only  four  years  old,  while  residing  in  the  country,  was  told 
not  to  leave  the  grounds  nor  to  go  on  the  street  alone.  He  was 
told  that  a  wagon  or  an  automobile  might  hurt  him  while  his 
attention  was  diverted  by  his  play.  One  evening  the  nurse 
informed  me  that  he  had  run  out  into  the  road.  I  said  to  him, 
"You  know  father  never  punishes  you  the  first  time  you  do 
something  wrong,  because  you  may  not  have  known  that  it 
was  wrong,  but  the  second  time  you  must  be  punished  because 
you  have  not  remembered  what  you  were  told.  Here,  how- 
ever, you  did  something  which  not  only  was  disobedient,  but 
you  endangered  your  life.  You  didn't  remember  what  I  told 
you  so  I  am  going  to  speak  to  you  through  your  skin,  so  that 
you  will  remember.  I  am  going  upstairs  to  change  my  clothes 
and  then  I  am  coming  down  to  teach  you  your  lesson." 

Here  I  learned  something  which  I  number  among  the 
best  lessons  of  my  life.  Without  a  word,  without  saying  "ex- 
cuse me"  or  "I  promise  never  to  do  it  again,"  he  got  down  on 
his  hands  and  knees  and  said,  "do  it  now,  and  have  it  over 
with."  You  may  imagine  how  I  felt  in  the  performance  of 
my  self-allotted  task.  I  went  around  for  three  days  feeling 
like  a  brute  until  my  judgment  finally  told  me  that  however  dis- 
tasteful it  may  be  to  compel  a  child  to  take  "castor  oil,"  never- 
theless the  end  justifies  the  means.  And  so  we  see  the  disad- 
vantages of  letting  any  form  of  punishment  hang  over  the 
heads  of  children  and  how  unwise  long  moral  talks  and  dis- 
sertations really  are,  when  the  purpose  may  be  defeated  by 
rousing  resentment  and  stimulating  the  instinct  of  contra- 
suggestion.  Discipline  also  develops  in  children  the  knowledge 
that  a  man  in  life  must  take  his  medicine.  If  you  say  to  a  child 
that  you  are  going  to  do  a  thing,  then  do  it. 

Nowhere  is  the  bad  effect  of  long  dissertations  on  be- 
havior, and  the  valuable  influence  of  prompt  and  immediate 
calm,  cool  disciplinary  measures  better  exemplified  than  the 
following  delightful  youthful  experience  of  Henry  Adams  and 


ENVIRONMENT  AND   HEREDITY  31 

his  subsequent  analysis  of  the  emotions  aroused  by  an  act  of 
discipHne, 

"He  could  not  have  been  much  more  than  six  years  old 
at  the  time — seven  at  the  utmost — and  his  mother  had  taken 
him  to  Ouincy  for  a  long  stay  with  the  President  during  the 
summer.  What  became  of  the  rest  of  the  family  he  quite  for- 
got, but  he  distinctly  remembered  standing  at  the  house  door 
one  summer  morning  in  a  passionate  outburst  of  rebellion 
against  going  to  school.  Naturally  his  mother  was  the  im- 
mediate victim  of  his  rage,  that  is  what  mothers  are  for,  and 
boys  also,  but  in  this  case  the  boy  had  his  mother  at  an  unfair 
disadvantage,  for  she  was  a  guest,  and  had  no  means  of  en- 
forcing obedience.  Henry  showed  a  certain  tactical  ability 
by  refusing  to  start,  and  he  met  all  efforts  at  compulsion  by 
successful,  though  too  vehement  protest.  He  was  in  fair  way 
to  win,  and  was  holding  his  own,  with  sufficient  energy,  at 
the  bottom  of  the  long  staircase  which  led  up  to  the  door  of 
the  President's  library,  when  the  door  opened,  and  the  old 
man  slowly  came  down.  Putting  on  his  hat,  he  took  the  boy's 
hand  without  a  word,  and  walked  with  him,  paralyzed  by  awe, 
up  the  road  to  the  town.  After  the  first  moments  of  con- 
sternation at  this  interference  in  a  domestic  dispute,  the  boy 
reflected  that  an  old  gentleman  close  on  eighty  would  never 
trouble  himself  to  walk  nearly  a  mile  on  a  hot  summer's  morn- 
ing over  a  shadeless  road  to  take  a  boy  to  school,  and  that  it 
would  be  strange  if  a  lad  imbued  with  the  passion  of  freedom 
could  not  find  a  corner  to  dodge  around  somewhere  before 
reaching  the  school  door.  Then  and  always,  the  boy  insisted 
that  his  reasoning  justified  his  apparent  submission,  but  the 
old  man  did  not  stop,  and  the  boy  saw  all  his  strategical  points 
turned,  one  after  another,  until  he  found  himself  seated  inside 
the  school,  and  obviously  the  center  of  curious  if  not  malevolent 
criticism.  Not  till  then  did  the  President  release  his  hand  and 
depart." 

"All  the  more  singular  it  seemed  afterwards  to  him  that 
his  first  serious  contact  with  the  President  should  have  been 
a  struggle  of  will,  in  which  the  old  man  almost  necessarily 


32  THE    ENDOCRINES 

defeated  the  boy,  but  instead  of  leaving,  as  usual  in  such  de- 
feats, a  lifelong  sting,  left  rather  an  impression  of  as  fair 
treatment  as  could  be  expected  from  a  natural  enemy.  The 
boy  met  seldom  with  such  restraint." 

"The  point  was  that  this  act,  contrary  to  the  inalienable 
rights  of  boys,  and  nullifying  the  social  compact,  ought  to 
have  made  him  dislike  his  grandfather  for  life.  He  could  not 
recall  that  it  had  this  effect  even  for  a  moment.  With  a  cer- 
tain maturity  of  mind,  the  child  must  have  recognized  that  the 
President,  though  a  tool  of  tyranny,  had  done  his  disreputable 
work  with  a  certain  intelligence.  He  had  shown  no  temper, 
no  irritation,  no  personal  feeling  and,  had  made  no  display  of 
force.  Above  all,  he  had  held  his  tongue.  During  their  long 
walk  he  had  said  nothing,  he  had  uttered  no  syllable  of  revolt- 
ing cant  about  the  duty  of  obedience  and  the  wickedness  of 
resistance  to  law,  he  had  shown  no  concern  in  the  matter, 
hardly  even  conscious  of  the  boy's  existence." 

"For  this  forbearance  he  felt  instinctive  respect.  He  ad- 
mitted force  as  a  form  of  right,  he  admitted  even  temper  under 
protest,  but  the  seeds  of  a  moral  education  would  at  that  mo- 
ment have  fallen  on  the  stoniest  soil  in  Quincy,  which  is,  as 
every  one  knows,  the  stoniest  glacial  and  tidal  drift  known  in 
any  Puritan  land." 

While  evidently  a  man  who  manifested  no  outward  evi- 
dences of  affection  and  was  not  demonstrative  in  this  respect, 
the  old  President  evidently  understood  the  nature  of  the  grand- 
son Henry,  as  can  be  seen  from  the  following: 

"Whether  his  older  brothers  and  sisters  were  still  more 
favored  he  failed  to  remember,  but  he  was  himself  admitted  to 
a  sort  of  familiarity  which,  when  in  his  turn  he  had  reached 
old  age,  rather  shocked  him,  for  it  must  have  some  time  tried 
the  President's  patience.  He  hung  about  the  library,  handled 
the  books,  deranged  the  papers,  ransacked  the  drawers, 
searched  the  old  purses  and  pocket-books  for  foreign  coins, 
drew  the  sword-cane,  snapped  the  travelling-pistols,  upset 
everything  in  the  corners,  and  penetrated  the  President's 
dressing-closet  where  a  row  of  tumblers,  inverted  on  the  shelf. 


ENVIRONMENT  AND   HEREDITY  33 

covered  caterpillars  which  were  supposed  to  become  moths  or 
butterflies,  but  never  did." 

Nagging 

If  some  children  grow  up  spoiled  and  full  of  faults  be- 
cause of  the  unwise  use  of  what  is  called  discipline  or  training, 
it  is  still  true  that  many  develop  well  in  spite  of  nagging.  If 
some  grow  up  good  and  excellent  under  admirable  training 
and  influences,  it  is  true  that  some  do  not  when  under  ap- 
parently the  same  influences.  The  same  form  of  management  of 
several  children  in  any  family  is  not  necessarily  correct ;  in  fact 
it  is  probably  decidedly  the  wrong  view.  It  pre-supposes  identi- 
cal instincts,  emotions,  endocrines  and  inherited  qualities.  If  we 
speak  of  the  same  environment  for  these  children  it  is  true 
only  in  the  physical  sense.  In  some  children  the  effects  of 
training  and  education  are  lasting;  in  others  not.  With  chil- 
dren, as  with  adults,  self-assertion  and  the  saying  "No"  too 
often  may  lead  to  no  worse  trials  than  the  inability  to  say, 
feel  or  do  "No."  This  latter  inability,  dependent  upon  the 
instinct  of  subjection  is,  in  the  grownup,  in  many  cases,  a 
serious  weakness,  though  in  the  family  relation  it  is  not  infre- 
quently the  only  quality  wdiich  saves  the  situation.  The  instinct 
of  subjection  may  lead  to  sad  or  harmful  experiences  accord- 
ing to  environment  and  the  character  of  the  temptations. 

Continual  nagging  is,  for  any  except  the  most  subjective, 
a  severe  irritation.  Ofttimes  the  perpetrator  is  quite  uncon- 
scious of  the  existence  of  this  manifestation  of  the  self-assertive 
instinct  or  the  contra-suggestive  tendency.  Because  it  is  a  de- 
lightful bit  of  reading  and  points  a  moral,  I  must  quote  from 
"Abraham's  Bosom"  the  following  concerning  the  patient  who 
had  taken  to  bed  because  of  an  incurable  illness : 

"He  sank  back  among  his  pillows  with  a  sigh  of  comfort. 
He  should  get  away  from  it.  (His  work  and  its  obligations.) 
Later  he  made  a  discovery  that  astonished  him  and  gave  him 
pain.  He  should  get  away  from  his  wife.  A  little  thing  re- 
vealed this  too,  as  an  escape.  Emily  had  bustled  into  his  bed- 
room with  a  cup  of  broth.     She  liked  plenty  of  salt  in  her 


34  THE    ENDOCRINES 

broth,  and  he  very  httle;  but  it  was  one  of  those  small  dif- 
ferences of  taste  to  which  she  had  never  become  reconciled. 
It  fretted  her  that  he  shouldn't  know  when  things  were  as 
they  ought  to  be ;  and,  not  to  fret  her,  he  had  during  two-and- 
thirty  years  submitted  to  her  wishes  docilely.  But  today  he 
felt  privileged  to  put  up  a  mild  protest. 

"  'Isn't  there  too  much  salt  in  this  broth,  dear?' 

"Standing  by  his  bedside,  she  took  the  cup  and  tasted  it. 

"  'No,  darling.     It's  very  good  indeed.     I  seasoned  it  my- 
self.    It's  exactly  right.' 

"  'Thanks,    dearest.'      As    broth   exactly    right,    he   forced 
himself  to  swallow  it. 

"Having  relieved  him  of  the  cup  she  went  on  to  make 
hini  comfortable.  He  had  been  comfortable  as  it  was,  but  she 
didn't  believe  it.  She  had  always  declared  that  if  he  would 
rest  as  she  did  he  would  get  more  repose.  She  proceeded, 
therefore,  to  show  him  how,  as  she  had  shown  him  how  per- 
haps a  million  times  in  the  course  of  their  life  together.  Pa- 
tiently he  allowed  himself  to  be  pulled  and  shunted  while  the 
sheets  were  straightened  and  the  pillows  smoothed,  and  he 
composed  his  figure  to  the  lines  that  suited  hers.  Patiently, 
too,  he  pretended  to  be  more  at  ease  than  he  had  been  before, 
though  he  was  saying  to  himself,  with  some  eagerness,  that 
death  would  take  him  away  from  this  worrying  wifely  affec- 
tion which  never  let  him  alone. 

"The  anticipation  gave  him  pangs  of  conscience,  since  they 
had  lived  together  with  quite  the  average  degree  of  happiness, 
and  he  loved  her  with  a  deep  and  quiet  love.  Moreover,  in 
spite  of  her  double  chin  and  her  increase  in  waist-line,  he  had 
never  ceased  to  see  in  her  the  timid,  wild-eyed  nymph  of  a 
thing  who  had  incarnated  for  him  all  that  was  poetry  in  the 
year  when  he  was  twenty-eight.  Not  till  after  their  first  child 
was  born  had  her  bird-like  shyness  yielded  by  degrees  to  an 
assumption  of  authority,  which  in  the  end  became  a  sort  of 
lordship  over  him.  By  the  time  they  had  three  children  she 
had  formed  the  habit  of  correcting  the  thousand  and  one  small 
faults  into  which  he  fell  without  knowing  it.    The  way  he  ate ; 


ENVIRONMENT  AND    HEREDITY  35 

the  way  he  sat  at  table ;  the  way  he  held  a  book ;  the  way  he 
coughed;  the  way  he  yawned;  the  way  he  shook  hands;  the 
way  he  pronounced  certain  of  his  words ;  the  way  he  gave  out 
his  notices  in  church;  the  way  he  allowed  other  men  to  walk 
over  him — these,  with  a  hundred  similar  details,  had  become 
the  sphere  of  her  loving  conjugal  discipline, 

''For  more  than  twenty  of  their  thirty-two  years  of  mar- 
ried life  her  comments  on  his  oddities  had  trickled  on  like  a 
stream  that  flows  and  stops,  and  stops  and  flows,  and  never 
dries  up  entirely.  He  had  borne  it  all  because  she  could  at 
any  time,  even  now,  throw  him  that  look  of  the  startled  dryad 
which  touched  some  hidden  spring  in  him;  but  the  moment 
had  arrived  when  he  couldn't  help  saying  that  he  would  be  glad 
to  get  away  from  it."     (Basil  King.) 

Parents  as  Teachers 

We  speak  of  ability  and  brains  as  if  they  were  matters 
of  education  only,  when  as  a  matter  of  fact  they  are  qualities 
inherent  in  the  individual.  They  may  be  moulded,  modified, 
extended.  The  acquisition  of  knowledge,  the  acquirement  of 
information  stamped  with  a  college  degree,  seems  to  be  consid- 
ered education.  But  education,  to  a  physician,  really  means  the 
bringing  out  of  the  best  in  an  individual,  the  covering  or  over- 
shadowing of  the  weaknesses.  Each  individual  represents  a 
certain  definite  amount  of  material  from  which  a  certain  definite 
result  may  be  obtained  by  the  use  of  the  best  and  most  highly 
scientific  methods.  The  best  method  would  be  to  have  a 
scientific,  well-understanding  individual  for  each  and  every 
child.  In  our  schools  teaching  is  group  teaching.  At  the 
present  birth-rate  the  average  child  will  soon  have  two  teachers 
in  the  persons  of  his  parents,  occasionally  only  one  for  each 
child.  The  problem  then  is  to  teach  parents  that  amount  of 
understanding  of  nature,  to  give  them  that  insight  into  psy- 
chology which  would  make  them  the  educators.  Let  the  child 
learn  at  school  its  three  Rs  and  all  the  other  factors  which  enter 
into  our  idea  of  education.  Let  it  learn  there,  if  possible,  the 
notions  of  patriotism,  honor,  manliness,  integrity.     Let  school 


36  THE    ENDOCRINES 

and  camps  allow  children  to  delve  into  nature's  wondei's  and 
develop  their  animal  spirits  in  a  wholesome,  healthful  way.  But 
in  the  hands  of  the  parents  must  rest  the  understanding  and 
consideration  not  only  of  the  principles  of  heredity  but  the 
hereditary  principles  in  their  children  which  would  make  the 
best  out  of  each  that  is  possible.  The  association  with  parents, 
the  affection  of  parents,  play  with  parents,  are  essential  to  the 
proper  development  of  the  child.  Heredity  and  psychology  are 
scientific  studies  of  the  reasons  for  behavior.  One  has  only  to 
study  and  observe  the  different  builds,  characters,  tempera- 
ments and  leanings  of  six  different  children  in  one  family  to 
realize  that  in  most  cases  the  parents  have  six  totally  different 
problems  to  contend  with.  From  the  study  of  the  principles 
of  heredity,  we  know  why  it  is  possible  for  them  to  be  different, 
but  that  will  not  solve  the  problem.  The  problem  is  one  of 
application.  In  development  we  observe  strikingly  the  ele- 
ment of  dovetailing,  antagonism,  and  overshadowing,  present- 
ing to  us  an  everchanging  picture  until  adolescence  presents 
an  individual  just  beginning  to  be  ripe. 

Whoever  has  read  Booth  Tarkington's  "Seventeen"  must 
have  been  delighted  with  the  mother  and  the  atmosphere  of 
motherliness  and  understanding  which  pervades  this  book. 

The  peculiarities  of  youth  are  often  enough  the  result  of 
physiological  developmental  changes.  Many  of  the  experiences 
are  needed  as  an  outlet  for  the  inward  prompting;  in  most 
cases  they  are  only  phases  of  gradual  development.  Growth, 
maturity  and  what  we  term  common  sense  in  some  cases  do  not 
appear.  All  do  not  acquire  this  so-called  common  sense,  but 
remain  of  the  same  mental  calibre  as  was  theirs  during 
adolescence.  If  individuals  with  psychic  and  mental  peculiar- 
ities were  observed,  studied  and  treated  with  understanding  of 
the  instincts,  emotions,  capabilities,  endocrines,  etc.,  and  with 
the  proper  consideration  and  valuation  of  these  points,  much 
harm,  trouble,  and  unhappiness  would.be  avoided.  And  it  is 
along  these  lines  that  the  physician  may  be  and  should  be  of  in- 
estimable value  to  the  parents  in  the  solving  of  many  of  their 
vexing  problems.     The  physician  should  understand  the  rela- 


ENVIRONMENT  AND   HEREDITY  7)7 

tion  of  ductless  glands  to  instincts,  emotions,  disposition  and 
character  as  well  as  their  all  important  relation  to  physical 
states;  in  fact  medicine  is  concerned  with  bacteria  on  the  one 
hand  and  the  ductless  glands  on  the  other  and  it  is  the  ductless 
glands  which  aid  the  living  body  in  the  perpetual  contest  with 
bacteria  and  bacterial  infections. 

Common  sense  and  the  understanding  of  children  are  not 
necessarily  the  result  of  education.  These  are  qualities  in- 
herent in  thousands  of  people  born  not  only  with  the  paternal 
and  maternal  instinct  but  with  a  natural  and  correct  under- 
standing of  the  nature,  qualities  and  possibilities  of  each  of 
their  several  children. 

I  have  a  friend,  the  owner  of  a  barber-shop,  Mr.  Gregg 
by  name.  Seated  in  his  chair  from  fifteen  minutes  to  a  half 
hour  on  hundreds  of  occasions,  I  have  learned  that,  with  his 
capabilities  and  common  sense,  he  should  have  been  the  presi- 
dent of  a  bank  or  trust  company.  He  has  said  to  me,  "I  say 
many  things  for  my  children,  but  not  to  my  children.  I  talk 
to  my  wife  when  we  are  at  table  and  I  know  that  my  children 
are  listening.  I  said  one  day  (he  has  two  sons  and  a  daugh- 
ter), "Mamma,  you  remember  my  speaking  often  of  Mr.  X. 
You  know  he  had  a  daughter  and  two  men  were  paying  her 
attention ;  one  was  much  better  looking  than  the  other,  but 
not  nearly  so  steady.  You  see  they  probably  didn't  tell  her  that 
good  looks  aren't  everything,  and  that  a  girl  wants  a  man  who 
has  no  disease  or  sickness  and  who  can  be  the  father  of  chil- 
dren ;  so  she  had  her  way  and  married  the  good  looking  fel- 
low, and  now  she  has  been  sick  ever  since.  She  is  going  to  be 
divorced ;  father  and  mother  are  all  broken  up  about  it ;  you 
know  she  is  the  only  daughter.  You  just  bet  that  any  young 
man  who  comes  around  here  looking  for  my  daughter's  hand 
has  got  to  look  good  to  me  first  and  after  that  a  good  doctor 
has  got  to  show  me  too  just  what's  what." 

Mr.  Gregg's  oldest  boy  wanted  to  study  medicine  and 
he  asked  my  opinion.  I  said,  "You  know,  it  means  several 
years  at  medical  school,  after  that  a  hospital  experience,  and 
then  a  good  many  lean  years  before  your  son  becomes  self- 


38  THE    ENDOCRINES 

supporting.  Can  you  finance  him  all  these  years,  and  then 
start  him  right  besides?"  "Yes,  I  can,"  answered  Gregg.  I 
replied,  "Put  it  to  him  just  that  way  and  if  he  is  still  determined 
and  starts  in  with  zeal  and  earnestness,  then  he  ought  to  be  a 
doctor  and  nothing  else.  But  with  the  manual  training  he  has 
already  had  at  high  school,  and  as  I  judge  him  from  my  ob- 
servation of  the  last  few  years,  I  think  some  form  of  engineer- 
ing is  more  adapted  to  his  abilities  and  he  will  be  able  to  marry 
much  earlier." 

After  nearly  a  year's  preparation  for  his  medical  work, 
which  experience  and  education  did  him  much  good,  he  felt 
the  call  of  his  real  capabilities ;  is  now  studying  electrical  en- 
gineering and  stands  among  the  leaders  of  his  class. 

A  Child's   Future 

Since  instincts  and  emotions  and  capabilities  are  respon- 
sible for  tastes,  likes  and  dislikes,  nothing  is  more  injurious 
than  to  be  fixed  in  an  unsympathetic  furrow  of  activity  whether 
it  be  one's  vocation  or  one's  environment.  Under  these  cir- 
cumstances the  best  cannot  be  evoked  but  is  repressed  and 
the  less  valuable  and  more  injurious  emotions  are  aroused. 
Parents  may  believe  a  certain  man  to  be  well-fitted  to  be  the 
husband  of  a  daughter  yet  he  may  not  be  compatible  and  the 
two  may  not  be  well-mated.  The  likes  and  dislikes  of  chil- 
dren and  the  new  generation  may  not  be  correctly  interpreted 
in  their  respective  cases  by  parents.  A  parent's  hopes  for  his 
children  may  be  frustrated  by  their  instincts,  emotions,  dis- 
positions and  character,  for  these  do  not  develop  in  our  off- 
spring as  we  will,  and  while  they  may  prove  less  perfect  or 
ideal  than  we  had  hoped,  yet  in  just  as  many  instances  they 
are  better;  and  neither  the  one  nor  the  other  may  be  our 
fault  or  to  our  credit,  though  they  are  so  often  enough. 

What  more  have  parents  a  right  to  wish  for  their  chil- 
dren than  that  they  should  grow  up  honest  and  honorable, 
healthy  and  well,  marry  happily  and  possess  enough  of  this 
world's  goods  to  gratify  and  satisfy  the  needs  of  the  Simple 
Life,   trusting  that   their    future   may   bring  them   not   only 


ENVIRONMENT  AND  HEREDITY  39 

happiness  but  that  contentment  and  peace  of  mind  which  comes 
from  properly  adapting  self,  capabilities  and  disposition  to  one's 
environment  and  to  one's  possibilities. 

As  I  have  quoted  the  wife's  attitude  toward  her  husband, 
and  his  instinct  of  subjection  and  her  instinct  of  self-assertion, 
let  me  quote  from  "Abraham's  Bosom"  the  father's  attitude 
toward  his  children: 

"And  then,  as  his  children  roamed  back  one  by  one  to 
see  him  die,  it  came  to  him  that  he  should  be  glad  to  get  away 
from  them.  That  was  a  discovery  which  shocked  him  to  the 
core.  His  children  had  been  part  of  himself.  They  had  been 
good  children,  too — on  the  whole.  There  w^ere  five  of  them, 
and  their  ages  ran  from  thirty-one  to  twenty-one.  From  a 
worldly  point  of  view  they  were  all  doing  reasonably  well — 
and  yet  they  were  doing  reasonably  well  in  ways  that  never 
turned  to  him  for  sympathy. 

"Berkeley,  Junior,  w^as  a  broker  in  New  York,  and  lived 
on  Staten  Island  with  a  wife  and  a  baby  son.  He  seldom 
came  home  now,  except  for  a  wedding  or  a  funeral.  The 
father  had  had  hopes  for  something  more  brilliant  for  the  lad 
in  the  year  when  he  was  born ;  hopes  that  had  grown  with  the 
boy's  growth  and  followed  him  to  school  and  college,  only 
to  fade  when  the  young  man  struck  out  for  himself. 

"Then  there  was  Constantia,  who  had  been  such  a  won- 
derful little  girl.  Beauty  and  cleverness  had  been  her  portion, 
with  a  command  of  the  piano  that  had  promised  the  career  of 
a  Carreno.  But  she  had  married  an  agnostic  professor  in  a 
Western  state  university,  where,  owing  to  the  necessity  of 
doing  her  own  housework,  she  had  given  up  her  music,  while 
in  submission  to  her  husband's  teaching  she  refused  to  let  her 
children  be  baptized. 

"The  twins,  Herbert  and  Philip,  were  in  modern  phases 
of  business,  the  one  selling  agricultural  implements  in  Texas, 
the  other  automobiles  in  Detroit.  There  was  nothing  a  father 
could  complain  of  in  this.  Berkeley  Noone  would  not  have 
so  much  as  sighed  if  it  hadn't  been  for  his  hopes.  They  had 
been  such  angelic  little  boys,  and  so  quick  at  everything.     He 


40  THE    ENDOCRINES 

had  placed  them  in  the  ideal  walks  of  life;  one  perhaps  as  a 
historian  or  philosopher,  and  one — one  at  least  as  a  clergy- 
man. But  they  had  preferred  the  great  career  of  making 
money,  and,  like  their  elder  brother,  rarely  came  home  now- 
adays. 

"Beatrice  was  the  enigmatic  one.  Though  but  twenty-two 
she  was  restless  and  eager,  and  sometimes  unhappy  in  ways  as 
to  which  she  never  gave  her  mother  or  himself  her  confidence. 
Nominally  living  at  home,  she  was  oftener  than  not  away  on 
the  pretext  of  studying  art.  All  he  knew  of  her  with  certainty 
was  that  she  moved  in  the  advanced  brigade  of  the  woman's 
agitation,  that  she  had  extraordinary  friendships  with  young 
men,  and  that  she  smoked  a  great  many  cigarettes.  Affec- 
tionate enough,  but  wilful  and  mysterious,  it  pleased  her  to 
keep  her  parents  in  ignorance  as  to  her  doings,  once  she  had 
closed  their  door  behind  her. 

"If  his  offspring  had  disappointed  him  it  was  not  precisely 
disappointment  that  had  worn  him  out;  it  was  a  sense  of  the 
futility  of  bringing  children  into  the  world  at  all.  He  had  put 
his  strength  into  theirs  and  they  hadn't  needed  it.  So  long 
as  they  had  let  him,  he  had  lived  their  lives  with  them,  and 
shared  their  struggles,  and  suffered  their  pains ;  he  had  yearned 
and  longed  and  looked  forward  for  themselves.  He  had  seen 
them  all  as  children  of  destiny!  Whatever  they  might  become, 
they  could  never  be  commonplace!  Even  wdien  they  had 
crosses  to  carry  and  cares  to  endure,  their  places  in  life  could 
never  be  anything  but  high  ones !  And  now — now  they  were 
all  there,  each  absorbed  in  what  seemed  to  him  a  merely  starve- 
ling way  of  life,  waiting  for  him  to  die  in  order  that  they  might 
return  to  it  as  quickly  as  steam  and  electricity  could  carry 
them.  Vitally  and  essentially  he  was  no  more  to  them  than 
the  parent  bird  to  the  robin  that  has  mated  and  made  its  nest 
in  another  tree." 

Encouragement 

If  the  influences  of  training,  example,  discipline,  punish- 
ment, reward,  appeal  to  the  emotions  and  to  the  understanding 


ENVIRONMENT  AND   HEREDITY  41 

are  so  important  in  children  then  the  same  principles  should 
hold  good  in  adults.  If  it  is  wise  to  avoid  instilling  fear  and 
wise  to  remove  fears  from  the  mind  of  the  child,  it  is  just  as 
important  to  do  so  in  one  psychically  or  mentally  ill. 

The  psychological  influence  of  the  promises  of  reward  or 
punishment  are  exemplified  in  religious  beliefs  and  teachings. 
As  civilization  advances  and  intelligence  becomes  more  widely 
distributed,  the  advantages  become  apparent  of  spreading  with 
this  teaching  the  doctrine  of  morality  and  of  moral  qualities, 
by  associating  proof  that  "it  pays."  The  stimulating  mental 
effect  of  hope  and  love  and  reward  are  becoming  more  recog- 
nized and  the  harmful  effects  of  fear  and  dread  are  becoming 
more  apparent.  One  child  takes  readily  to  discipline,  another 
child  may  be  refractory  to  it  because  of  the  powerful  develop- 
ment of  the  instinct  of  self-assertion  and  the  eijiotion  of  ela- 
tion; or  because  the  instinct  of  contra-suggestion  is  more 
assertive  than  the  instinct  of  subjection.  Every  physician 
knows  patients  who  trust  in  him,  follow  his  advice  implicitly, 
and  feel  better  when  in  his  presence.  On  the  other  hand,  there 
are  other  patients  to  whom  one  renders  medical  service  only 
as  a  matter  of  duty;  they  are  instinctively  assertive  and  con- 
tra-suggestive ;  they  do  not  follow  advice  or  else  so  unwillingly, 
make  exacting  demands,  expect  more,  and  demand  more  im- 
mediate attention  than  is  possible,  and  are  rather  a  burden 
than  a  pleasure.  But  just  because  of  this  trend  of  their  in- 
stincts and  emotions,  some  must  be  treated  firmly  or  sternly, 
like  some  children ;  others,  like  older  children,  must  be  shown 
the  errors  of  their  w^ays,  though  it  require  tact  and  the  exer- 
cise of  all  one's  patience.  If  confidence  and  obedience  do  not 
develop,  the  doctor  is  better  off  if  the  patient  is  requested  to 
find  a  physician  who  can  find  the  instinct  of  subjection.  The 
encouragement  of  patients,  the  removal  of  their  doubts  or 
fears,  the  explanations  that  physical  and  mental  asthenia  or 
psychic  excitability,  etc.,  have  a  physical  and  glandular  basis, 
tends  to  promote  their  self-respect  and  help  them  to  retain 
their  courage.  How  unwise  it  is  to  repeatedly  throw  upon  a 
child  reproof  or  blame  for  the  manifestations  of  certain  emo- 


42  THE    ENDOCRINES 

tions,  or  of  forms  of  behavior,  when  the  wise  medical  man  can 
explain  them  on  the  basis  of  instincts  and  emotions  which 
the  very  attempts  at  rigid  discipline  may  bring  out,  to  the  harm 
and  injury  of  the  child.  How  many  children,  who  are  not 
musical  and  dread  the  tedium  of  practicing,  are  made  to  con- 
tinue at  this  unsympathetic"  but  supposedly  essential  element  of 
their  education,  acquiring  eventually  a  technique  which  they 
never  use  in  after  life. 

A  child  who  needs  plenty  of  sleep,  who  is  tired  when 
awakening  in  the  morning,  who  dresses  slowly,  is  late  at 
school,  yawns  over  the  school-work,  is  slow  in  completing  its 
school-tasks  for  the  next  day,  may  be  hypothyroid  even  if  only 
temporarily,  or  hypopituitary,  may  suffer  from  adenoids,  may 
be  going  through  a  transitional  adjustment  or  readjustment 
of  glandular  and  physical  function,  may  be  passing  through  an 
unrecognized  tuberculous  process,  that  process  which  affects 
most  people  at  one  time  or  other  of  their  life,  in  the  huge  num- 
ber of  cases  unrecognized,  that  process  which  finally  renders  the 
vast  majority  immune  to  tuberculosis  in  after  life;  but  which 
persists  with  varying  types  of  infirmities  in  those  more  sus- 
ceptible and  the  less  resistant. 

Not  only  is  there  injustice  in  criticisms  and  scoldings  of 
the  above  type  when  the  child  is  really  in  need  of  medical  at- 
tention, but  the  psychic  effect  of  continued  reiterations  of 
words  like  lazy,  stupid,  indolent,  etc.,  diminish  the  child's  self- 
respect;  and  the  degree  to  which  treatment  increases  the  in- 
stinct of  subjection  and  diminishes  the  instinct  of  self-asser- 
tion with  its  normal  emotion  of  elation  and  of  confidence,  can 
only  be  too  readily  recognized  in  after  life. 

After  the  above  was  long  set  down  in  writing.  I  saw  the 
following  lines  by  Joan  Benedict,  which  I  think  too  valuable 
to  omit : 

"We  have  quoted  much  from  the  late  Col.  Roosevelt's  ■ 
letters  to  his  children.     We  are  struck  in  a  number  of  the 
letters  with  the  father's  way  of  bringing  out  the  best  in  his 
children,  his  conjuring  up  by  a  mighty  expectation  qualities 
which  undoubtedly  were  in  the  children  anyhow,  but  which 


ENVIRONMENT   AND   HEREDITY  43 

this  father  of  fathers  summons  to  the  fore  by  a  superb  taking 
for  granted  that  amounts  ahnost  to  hypnotism.  'I  know  you 
are  studying  hard,'  he  writes  to  one  son  at  preparatory  school, 
and  though  in  the  next  letter  to  the  same  son  the  father  says 
he  is  puzzled  by  the  report's  low  marks  he  suggests  an  ex- 
planation himself  in  no  way  reflecting  upon  the  boy's  ability 
or  industry.  'I  have  faith  in  your  energy,'  concludes  a  letter 
that  might  well  have  concluded  another  way;  'in  your  per- 
severance, your  ability  and  your  power  to  force  yourself  to 
the  front  when  you  have  once  found  out  and  taken  your  line.' 
And  again,  'you  have  gone  in  with  the  serious  purpose  of 
doing  decently  and  honorably,  of  standing  well  in  your  studies 
and  of  getting  the  respect  and  liking  of  your  classmates  so 
far  as  they  can  be  legitimately  attained." 

"All  through  these  letters  of  Theodore  Roosevelt  to  his 
children  breathes  the  spirit  of  'I  believe  in  you.'  The  chil- 
dren of  such  a  father  could  not  fail.  We  can  but  contrast  it 
with  that  of  that  other  parental  attitude,  all  too  common,  that 
the  child  is  usually  to  blame  and  mostly  in  the  wrong  being 
a  child.  The  parental  power  of  suggestion  goes  a  long  way 
toward  building  up  or  pulling  down  character  yet  in  the  mak- 
ing. 

Initiative 

One  might  say  that  environment  fixes  the  type.  It  is  more 
true  that  types  seek  an  appropriate  environment.  The  man 
with  Wanderlust  wanders.  The  Puritans  sought  a  land  in 
which  they  could  give  expression  to  their  thoughts  and  ideas. 
The  pioneer  sought  new  lands  because  that  adventurous  qual- 
ity of  his  nature  prompted  him.  The  lazy,  indifferent,  un- 
energetic  stick  to  failing  fields,  even  when  it  is  apparent  that 
they  are  of  no  promise.  John  Ferguson  prayed  and  did  little 
else — and  as  a  result  he  sacrificed  his  son  whose  impulses  were 
strong  and  human,  whereas  the  world  could  easily  have  spared 
the  father.  Most  churches  do  not  make  all  their  pew-holders 
good  and  truly  religious.  It  is  primarily  the  good  and  religious 
who  support  the  churches.    The  boy  or  man  of  energy  and  ini- 


44  THE    ENDOCRINES 

tiative  seeks  a  sympathetic  field.  The  less  energetic,  the  less 
sure  of  himself,  the  one  less  actuated  by  a  positive  leaning  is 
more  uncertain  of  his  choice.  The  least  energetic  and  the 
least  sure  amount  to  the  least.  Advice,  encouragement  and  a 
proper  selection  made  for  him  may  put  him  in  a  place  most 
favorable  to  the  development  and  use  of  the  faculties  he  pos- 
sesses. Nothing  makes  a  boy  or  girl,  man  or  vv^oman  unhap- 
pier  than  an  occupation  or  environment  for  which  he  is  not 
fitted.  So-called  "Luck"  is  the  result  ofttimes  of  being  vi^here 
"one  belongs"  at  the  right  time  or  age  or  stage.  A  man  who 
succeeds  in  business  deserves  his  success  and  deserves  credit 
for  energy,  foresight  and  push  even  if  he  have  no  higher  edu- 
cation or  college  degree.  The  best  of  a  college  education,  in 
many  cases,  is  that  it  keeps  the  immature  and  hesitant  from 
choosing  before  he  knows  what  he  wants. 

College  is  necessary  for  the  surgeons,  the  lawyers,  the  doc- 
tors, the  teachers,  etc.,  but  what  a  boy  or  girl  learns  in  four 
years  at  college  as  knowledge  means  little.  If  he  learns  how 
to  study,  to  analyze,  to  digest,  he  has  profited.  All  else  he 
can  read  out  of  college  as  well  as  within  its  walls.  If  a  man 
succeeds  after  college,  he  had  good  stuff  in  him  and  went  to 
college  for  good  reasons;  but  his  collegiate  education  (unless 
tech.)  did  not  make  him,  although  it  helped  him. 

The  boy  who  after  college  makes  no  success  simply  did 
not  have  it  in  him.  What  sent  him  to  college  was  not  that  im- 
pulse which,  when  reviewed  in  after  life  in  the  successful  man, 
made  that  man  a  success.  If  boys  or  girls  acquire  an  exag- 
gerated notion  of  the  meaning  of  a  degree,  if  they  value  suc- 
cess too  little,  if  they  fail  to  understand  that  energy,  brains  are 
inherent  qualities,  they  then  fail  to  give  proper  consideration 
and  appreciation  to  people  who  possess  these  qualities.  A  col- 
lege girl  may  acquire  a  false  sense  of  values;  a  college  man 
oft  has  a  false  and  exaggerated  sense  of  his  value.  It  creates 
a  separation  instead  of  a  community  of  interest  or  respect.  It 
interferes  with  team  work.  People  are  to  be  jvidged  by  what 
they  do,  not  by  what  they  know,  and  if  in  education  we  brought 
out  ability  to  do,  to  control,  to  understand,  to  value  things 


ENVIRONMENT   AND   HEREDITY  45 

properly,  there  would  be  more  sympathy,  more  of  the  demo- 
cratic spirit. 

Soldiers  do  not  obey  officers  and  yield  to  discipline  be- 
cause they  think  or  unconsciously  decide  to  do  so.  It  is  be- 
cause they  know  that  they  must  and  that  "must''  gets  into  their 
system  and  so  by  discipline  a  perfect  machine  is  developed. 
No  man  can  make  others  obey  who  does  not  know  or  has  not 
practiced  obedience.  What  is  moral,  right,  wholesome,  etc., 
makes  a  stronger  appeal  if  one  knows  it  is  for  his  own  good, 
if  "it  pays." 

Teaching  physical  morality  to  children  and  young  men 
will  bring  better  results  if  taught  on  other  grounds  than  only 
the  moral  or  ethical.  No  one  wishes  to  do  what  may  harm 
him,  what  may  be  followed  by  severe  and  lasting  consequences. 
If  that  picture  be  exhibited  while  the  moral  lecture  is  given,  an 
increasing  effect  is  produced.  The  nations  which  first  adopted 
social  refinement  did  it  not  because  of  highly  generous  or  moral 
principles,  but  because  they  figured  and  knew  that  it  "would 
pay." 

To  attain  a  desired  result,  whatever  method  is  used,  the 
attainment  of  the  result  is  the  objective,  and  if  action  does  it  bet- 
ter than  words,  then  action  is  the  thing.  If  example  is  more 
inspiring  than  the  thing  taught,  then  example  is  one  of  the 
greatest  forces,  as  we  know  it  to  be.  Imitation  is  at  the  bottom 
of  most  things  the  child  acquires,  especially  in  its  earlier  years, 
Hence  bad  associations  have  their  contagious  influences. 

Advice 

In  "Erewhon"  Samuel  Butler  describes  a  make-believe 
land  where  physical  ailments  are  considered  a  crime  against 
law  and  order ;  but  moral  obliquity  and  peculiarities  of  disposi- 
tion and  character  are  held  to  constitute  illness.    He  says : 

"If  a  man  falls  into  ill  health  or  catches  any  disorder 
or  fails  bodily  in  any  way  before  he  is  seventy  years  old, 
he  is  tried  before  a  jury  of  his  countrymen,  and  if  con- 
victed, is  held  up  to  public  scorn  and  sentenced  more  on 
less  severely  as  the  case  may  be.     But  if  a  man  forges  a 


46  THE   ENDOCRINES 

check  or  sets  his  house  on  fire  or  robs  with  violence  from 
a  person,  he  is  either  taken  to  a  hospital  and  most  care- 
fully tended  at  the  public  expense  or,  if  he  is  in  good  cir- 
cumstances, he  lets  it  be  known  to  all  of  his  friends  that 
he  is  suffering  from  a  severe  fit  of  immorality.  Bad  con- 
duct, though  considered  no  less  deplorable  than  illness,  as 
with  ourselves  and  as  unquestionably  indicating  some- 
thing seriously  wrong  with  the  individual  who  misbe- 
haves, is  nevertheless  held  to  be  the  result  of  either  pre- 
natal or  postnatal  misfortune. 

"All  the  ordinary  greetings  among  ourselves,  such 
as  'how  d'ye  do,'  are  considered  signs  of  gross  ill-breed- 
ing. They  salute  each  other  with  'I  hope  you  are  good 
this  morning,'  or  'I  hope  you  have  recovered  from  the 
snappishness  from  which  you  were  suffering  when  I  last 
saw  you.' 

"There  exist  a  class  of  men  trained  in  soul-craft 
whom  they  call  straighteners,  meaning  those  'who  bend 
back  the  crooked.'  The  straighteners  have  gone  so  far 
as  to  give  names  to  all  known  forms  of  mental  indisposi- 
tions and  to  classify  them  according  to  a  system  of  their 
own,  which,  though  I  could  not  understand  it,  seemed  to 
work  well  in  practice. 

"So  the  Erewhonians  take  a  flogging  once  a  week 
and  a  diet  of  bread  and  water  for  two  or  three  months 
together  whenever  their  straightener  recommends  it." 

The  prescription  which  was  given  to  a  wealthy  em- 
bezzler was  described  as  follows : 

"It  ordered  a  fine  to  the  state  of  double  the  money 
embezzled;  no  food  but  bread  and  milk  for  six  months 
and  a  severe  flogging  once  a  month  for  twelve.  In  mak- 
ing the  diagnosis,  the  straightener  was  told  by  the  patient 
that  he  feared  that  his  morals  must  be  permanently  im- 
paired. The  eminent  man  reassured  him  with  a  few 
cheering  words  and  then  proceeded  to  make  a  most  care- 
•  ful  diagnosis  of  the  case.  He  asked  about  the  moral 
health  of  his  parents.     He  was  answered  that  there  had 


ENVIRONMENT  AND  HEREDITY  47 

not  been  anything  seriously  amiss  with  them  but  that 
his  maternal  grandfather,  whom  he  was  supposed  to  re- 
semble somewhat  in  person,  had  been  a  consummate 
scoundrel  and  had  ended  his  days  in  a  hospital;  while  a 
brother  of  his  father,  having  led  a  most  flagitious  life  for 
many  years,  had  at  last  been  cured  by  a  philosopher  of  a 
new  school." 

In  this  most  amusing  book  about  an  imaginary  land,  we 
see  that,  while  they  are  far  behind  modern  countries  in  that 
they  do  not  tolerate  practitioners  or  physicians  whose  function 
is  to  cure  physical  ills,  the  inhabitants  set  us  an  example  in 
their  appreciation  of  the  fact  that  many  mental  and  moral 
states  are,  at  least  in  their  opinion,  truly  ills.  And  if  we 
are  far  superior  to  them  in  our  attention  to  body  ailments,  I 
think  that  our  present  trend  is  towards  looking  to  the  physician 
to  be  a  mental  straightener,  and  that  this  trend  promises  to 
soon  make  us  equal  to  the  Erewhonians  in  that  respect. 

Physical  processes  which  are  associated  with  and  due  to 
endocrine  abnormality  are  a  most  potent  cause  of  neuroses, 
states  of  anxiety  and  psychoses. 

It  is  important,  however,  for  the  physician  to  recognize 
that  psychic  irritations  have  a  profound  effect  on  patients' 
physical  functions  and  mental  well-being.  It  is  of  the  utmost 
importance  that  he  should  realize  that  the  unhappy  events 
of  life,  its  disappointments,  its  strifes,  are  important  causal 
factors.  A  physician  must  decide  whether  a  state  of  nervous- 
ness or  irritability  or  excitability  or  depression  is  due  primarily 
or  secondarily  to  abnormal  interglandular  activity,  the  char- 
acter of  which  he  must  seek  to  diagnose.  This  may  be  due  to 
or  influenced  by  conditions  in  the  pelvis  involving  the  uterus, 
ovaries,  etc.,  since  they  are  closely  related  to  the  endocrine 
chain.  If  so,  the  correction  of  the  pelvic  condition  will  im- 
prove not  only  the  patient's  physical,  but  her  psychic  state, 
and  restore  her  to  the  normal.  But  just  because  a  patient  with 
a  neurosis  or  a  psychosis  has  a  slight  vaginal  cervical  or  uterine 
abnormality,  we  should  not  say  that  it  is  the  causal  factor. 
The  cause  is  often  a  disturbed  endocrine  relation  and  the  pelvic 


48  THE    ENDOCRINES 

condition  may  not  and  often  does  not  have  anything  to  do 
with  the  neurosis  and  psychosis.  It  is  probable  that  a  care- 
ful history  will  often  disclose  an  infectious  disease  or  influenza 
as  the  etiological  factor  leading  to  physical,  metabolic,  endo- 
crine and  psychic  changes.  This  holds  true,  likewise,  of 
nephritic  changes  and  blood  pressure. 

Now  a  physician  by  giving  the  correct  explanation  may 
modify  to  a  great  extent  a  patient's  fears.  He  is  able  to 
assure  her  that  she  has  no  cancer,  that  her  fibroid  is  not 
malignant,  that  her  retroflexion  and  her  prolapsed  ovaries, 
while  responsible  for  many  of  her  local  and  general  symp- 
toms, do  not  constitute  a  condition  that  will  shorten  her  life, 
that  an  operation  for  descent  of  the  uterus  or  a  repair  of  a 
relaxed  vaginal  outlet  will  increase  her  efficiency  as  an  active 
person.  He  may,  on  the  other  hand,  explain  to  another  that 
she  is  tired  and  languid,  depressed  and  inelastic  because  her 
endocrines  were  exhausted  by  a  pregnancy  and  labor.  He  may 
explain  to  another  that  her  excitability,  irritability,  nervous- 
ness, restlessness  and  various  mental  phenomena  of  the  same 
sort  appearing  regularly  before  each  menstruation  are  due  to 
plus  or  minus  of  one  or  more  of  the  glands  in  the  altered 
interaction  taking  place  so  often  at  the  premenstrual  period. 
If  a  patient  realizes  that  her  moods  and  her  behavior  at  this 
time  are  expressions  of  gland  processes  going  on  within  her 
and  that  only  to  a  limited  degree  is  she  responsible,  in  many 
cases,  for  the  manifestations  of  this  gland  action,  as  evidenced 
by  her  attitude  and  her  behavior,  many  a  woman  ceases  to 
blame  herself  for  lack  of  will  power. 

It  has  happened  in  my  practice  so  often  that  I  must  re- 
count a  typical  case.  A  patient  who  has  had  one  baby  comes 
to  my  office  with  her  husband.  He  wishes  to  see  me  a  moment 
before  his  wife  comes  in.  Tells  me  that  she  is  nervous  and 
hysterical  and  that  I  should  take  this  into  consideration  when 
she  consults  me.  Her  story — since  her  baby  is  born,  she  is 
tired  and  languid.  Has  a  backache  and  feels  a  sensation  of 
dropping  dow-n,  has  no  desire  to  go  out,  is  too  tired  at  night  to 
go  to  the  theatre  or  to  dance,  is  nervous,  depressed  or  irritable. 


ENVIRONMENT  AND   HEREDITY  49 

very  sensitive,  cries  easily.  After  further  questioning,  it  is 
apparent  that  her  husband  is  impatient,  tells  her  to  brace  up,  to 
be  like  she  used  to  be.  Then  some  relative  tells  her  that  for  her 
husband's  sake  she  should  brace  up.  (That  seems  to  be  the 
most  frequently  used  phrase.)  She  is  told  that  she  is  nervous 
and  hysterical  and  finally  comes  to  believe  that  she  is,  loses 
respect  for  her  will-power  and  is  ready  to  believe  almost  any- 
thing- of  herself. 

When  this  patient  is  examined  we  find  the  uterus  retro- 
flexed  or  ''upside  down,"  as  we  explain  to  the  patient;  her 
ovaries  are  displaced,  her  endocrine  balance  is  upset  and  gen- 
erally minus  ;and  she  is  suffering  from  asthenia  after  preg- 
nancy and  labor,  from  altered  ovarian  secretion,  due  to  displace- 
ment of  the  uterus  and  ovaries.  We  assure  the  patient  that 
the  uterus  can  probably  be  temporarily  replaced  and  held  in 
position  by  a  pessary,  that  several  weeks  of  care  and  attention 
plus  the  tonic  effect  say.  of  suprarenal  extract,  pituitary  extract 
and  possibly  thyroid,  plus  other  procedures  will  improve  her 
digestion  and  metabolism,  that  she  will  soon  feel  well,  and  the 
matter  of  operative  correction  of  her  displaced  uterus  can,  if 
desired,  be  left  for  a  future  period. 

The  astounding  change  in  the  patient's  attitude  is  ap- 
parent at  once.  She  now  knows  that  she  is  not  a  nervous  or 
hysterical  "wreck,"'  because  of  lack  of  will-power;  she  knows 
that  there  is  a  physical  and  endocrine  basis  for  her  condition. 
She  can  now  face  her  family  and  friends  with  the  knowledge 
that  "there  is  a  reason"  and  a  good  one  too  which  both  she 
and  her  husband  have  readily  understood.  And  what  is  not 
least  in  importance,  the  husband's  attitude  changes  at  once.  He 
realizes  that  his  wife  has  been  and  is  ill.  even  though  her  color 
be  good  and  even  though  she  appear  plump  and  robust.  The 
psychic  effect  on  both  in  the  influencing  of  their  subsequent 
behavior  can  be  readily  estimated. 

It  is  in  the  power  of  the  physician  to  offer  advice  on 
many  novel  points  associated  with  health  and  mental  comfort. 
He  may  advise  rest  before,  during  or  after  menstruation.  He 
may  advise  that  the  douches  prescribed  be  continued  during 


50  THE   ENDOCRINES 

menstruation,  which  information  usually  startles  most  women 
though  it  is  a  most  sanitary  habit.  Pregnant  women  can  be 
truthfully  informed  that  the  foetus  encased  in  its  shell  and 
floating  in  fluid  cannot  be  altered  or  injured  by  grief,  worries 
or  mental  shock  on  the  part  of  the  mother,  that  it  is  the  product 
of  an  ovum  and  a  spermatozoon  and  will  develop  according  to 
the  laws  of  heredity. 

That  many  women  suffer  various  annoyances,  physical, 
psychic  and  mental,  at  the  menopause  is  to  be  explained  on  the 
ground  that  the  rearrangement  of  gland  activity  brings  out 
latent  weaknesses  or  produces  decided  changes.  That  such 
results  are  no  more  likely  to  occur  but  less  likely  to  occur  if 
the  uterus  is  removed  before  the  menopause  has  been  proven 
to  me  sufficiently  by  my  own  experience. 

Women  when  told  that  an  operation  will  be  followed  by 
a  cessation  of  menstruation  are  often  startled  since  they  have 
heard  and  thought  that  early  cessation  of  menstruation  changes 
their  disposition,  alters  their  nature  and  removes  many  of  the 
more  lovable  feminine  traits.  We  may  assure  them  that  men- 
struation with .  its  premenstrual  phenomena,  its  recurring  en- 
docrine upset,  the  frequently  associated  pain  and  discomfort, 
the  loss  of  blood  constitute  the  price  that  women  pay  for  the 
privileges  of  motherhood.  We  tell  them  that  the  uterus  is 
simply  a  nest  in  which  the  impregnated  ovum  settles  and 
grows.  We  further  assure  them  that  a  uterus  which  cannot 
be  or  should  not  be  again  used  as  a  nest  is  a  useless  organ.  We 
can  safely  assure  them  that  while  removal  of  the  ovaries  may 
be  followed  by  severe  flushes  and  flashes,  the  severity  of  which 
can  be  markedly  diminished  by  ovarian  secretion  if  given  early 
enough,  that  removal  of  the  uterus  with  retention  of  one  or 
both  ovaries  is  usually  followed  after  a  few  months  or  years 
by  only  slight  flushes  and  that  these  can  be  readily  controlled 
as  they  appear;  and  that  they  are  rarely  as  severe  as  are  the 
annnoyances  noted  in  many  cases  of  normally  acquired  meno- 
pause at  the  climacterium  age.  It  may  seem  strange  to  advise 
a  removal  of  the  uterus  with  retention  of  the  ovaries  to  cure 
premenstrual  and  menstrual  phenomena,  and  to  remove  the 


ENVIRONMENT  AND  HEREDITY  51 

irritation  imparted  to  the  gland  chain  by  menstruation;  but 
this  advice  I  have  often  given.  No  woman  is  as  well  as  she  is 
after  menstruation  has  ceased  by  orderly  rearrangement  of 
the  glands  at  menopause. 

It  is  possible  by  judicious  advice,  coupled  with  the  ex- 
planation that  "it  pays,"  to  aid  patients  in  avoiding  or  tem- 
pering the  intensity  with  which  external  stimuli  act  upon  the 
emotions.  A  famous  actress,  exceedingly  emotional  as  we 
call  it,  and  remarkable  for  her  exceptional  work  on  the  dra- 
matic stage,  had  been  a  patient  of  mine  for  many  years.  She 
consulted  me  one  day  and  stated  that  she  was  practically  ex- 
hausted, not  by  her  work  alone,  but  by  the  annoyances,  the 
violations  of  rules  and  the  lax  observance  of  the  qualities  of 
earnestness  on  the  part  of  the  company.  The  spirit  of  rest- 
lessness, insubordination  and  Bolshevism,  she  said,  had  in- 
vaded her  company  and  she  was  driven  to  distraction.  I  said 
to  her,  "You  must  do  something  for  yourself.  You  must  put 
a  screen  between  these  irritations  and  yourself,  pay  no  atten- 
tion to  them  and  determine  not  to  notice  them.  The  more 
your  company  see  that  you  are  irritated,  the  more  likely  they 
are  to  continue  to  annoy  you.  Secondly,  you  must  put  a  shock 
absorber  or  a  transformer  between  the  observed  irritations 
and  yourself.  Your  judgment  and  your  determination  to  be 
calm  will  diminish  or  inhibit  the  intensity  of  the  reaction. 
When  the  mosqultos  are  buzzing  in  your  room,  you  throw  a 
mosquito-netting  over  you,  do  you  not?  You  say,  'Let  them 
buzz;  I  know  they  can't  sting  me  and  I  can  go  to  sleep.'  If 
you  find  that  the  buzzing  does  keep  you  awake,  you  put  cotton 
in  your  ears  and  so  far  as  you  are  concerned  there  is  no  buzz 
and  there  is  no  sting.  She  answers,  Why  must  there  be 
mosquitoes  in  the  world.'  I  replied,  'Mosquitoes  and  vermin, 
like  troubles,  serve  an  excellent  purpose.  They  force  us  to  be 
clean  and  sanitary  or  else  our  senses  are  affected  by  smells,  our 
digestion  is  affected  by  ptomaines,  our  skin  is  irritated  by  bites 
and  stings.  It  was  the  knowledge  that  malaria  and  yellow 
fever  are  caused  by  the  mosquitoes  bred  and  grown  in  wet, 
damp,  dirty  places,  that  made  people  keep  their  kitchens,  yards 


52  THE    ENDOCRINES 

and  out-houses  clean.  The  experience  that  typhoid  fever  is 
conveyed  through  water,  milk,  etc.,  has  made  for  sanitation, 
cleanliness  and  the  protection  of  v^ater  supply.  When  the 
wealthy  man  with  the  beautiful  country  estate  finds  life  made 
unbearable  by  the  mosquitoes  and  he  is  told  that  by  draining 
the  marsh-lands  about  him  he  removes  their  breeding  spots 
forever,  he  and  his  neighbors  dredge  a  channel  to  an  inlet  or 
the  ocean,  pump  sand  upon  the  drained  area,  get  rid  of  the 
mosquitoes,  find  the  channel  a  lovely  outlet  for  their  motor- 
boats  and  find  upon  their  hands  hundreds  of  acres  of  valuable 
land  and  realize  that  "it  pays."  These  little  irritations  put 
you  to  the  test'  ", 

So  with  a  little  bromide  and  an  occasional  sleeping  pow- 
der and  an  invisible  mosquito-netting  placed  by  her  will-power 
and  judgment,  between  the  mosquitoes  of  her  company  and 
herself,  she  got  along  famously. 

One  of  the  most  valuable  things  a  physician  can  do  is  to 
use  his  knowledge  of  human  nature  and  of  medicine  in  im- 
parting information,  and  that  not  so  infrequently,  to  those 
misguided  and  misinformed  young  married  people  who  wish 
to  be  relieved  of  a  pregnancy  because  they  are  not  ready  yet 
or  because  they  are  only  married  a  very  short  time,  or  because 
it  interferes  with  their  plans.  They  are  perfectly  willing  to 
have  a  baby  in  a  year  or  two,  but  they  are  not  just  ready  yet. 
The  first  impulse  of  the  physician  is  to  assert  his  dignity  and 
the  dignity  of  his  profession  and  to  resent  what  is  really  an 
insult  even  though  not  so  intentioned.  But  if  the  physician, 
figuratively  speaking,  puts  such  a  prospective  mother  out  of 
his  office,  he  may  throw  her  into  hands  more  receptive  to  the 
suggestion.  It  has  been  my  good  fortune  on  occasion  to  save 
this  life  by  explaining  that  it  was  morally  wrong  for  the  pros- 
pective mother  to  harbor  such  a  wish ;  that  it  was  morally  and 
legally  wrong  for  the  physician  to  interfere  with  what,  though 
she  felt  it  not,  was  nevertheless  a  living  and  growing  embryo ; 
that  interference  could  result  in  changes  in  the  ovaries  and 
other  structures  which  might  prevent  her  from  ever  becoming 
pregnant  again  and  then  her  whole  life  would  be  marred  by 


ENVIRONMENT  AND    HEREDITY  53 

an  ungratified  longing  for  offspring  and  a  continued  regret 
that  she  had  of  her  own  volition  been  responsible  for  this 
deprivation;  that  children  are  the  greatest  of  all  joys  and  that 
while  man  proposes  nature  knows  better  than  to  always  leave 
in  the  hands  of  the  human  being  the  decision  as  to  w^hen  chil- 
dren should  be  born.  One  would  have  had  little  respect  for 
nature  and  the  omniscience  of  the  Almighty  if,  for  instance, 
the  sex  of  children  were  a  matter  which  human  beings  could 
influence  at  all. 

In  his  relationship  with  patients  the  physician  has  oppor- 
tunity in  a  dignified  and  pleasant  manner  to  bring  an  occa- 
sional smile  to  a  patient's  face  and  to  tell  her  that  smiles  are 
like  rays  of  sunshine.  Yet  he  must  realize  that  some  patients 
are  not  clever  and  that  some  are  contrasuggestive.  In  the 
postoperative  convalescence  the  surgeon  can  cheer  a  patient 
very  often  by  a  kind  greeting  or  a  little  pleasantry.  I  know  a 
surgeon  wdio,  when  a  patient  was  sitting  up  on  the  tenth  day 
after  an  operation,  bedecked  with  a  boudoir  cap  and  pretty 
ribbons,  said  to  the  nurse,  "Our  patient  looks  so  well  this  morn- 
ing I  think  we  ought  to  send  for  the  house  photographer." 
The  patient  replied,  "You  had  better  keep  your  compliments 
for  your  wafe."  The  surgeon  did  not  enter  her  room  again 
during  the  remainder  of  her  convalescence.  If  some  patients 
are  not  clever  it  is  true  that  an  occasional  physician  likewise 
fails  to  understand  human  nature. 

A  very  charming,  dignified  mother  whose  oldest  child  w^as 
twenty-one  years  of  age,  a  woman  who  is  interested  in  child 
welfare  and  takes  part  in  political  activities,  visited  a  clinic 
and  before  seeing  the  surgeon  was  ushered  into  a  room  where 
the  histories  are  taken.  A  very  well-dressed  and  rather  youth- 
ful doctor  gave  her  a  casual  glance  and  in  a  perfectly  mechan- 
ical manner  took  her  history.  When  he  finished  he  said, 
without  looking  up,  "Well,  I  think  we  will  have  to  put  you 
down  as  that  bundle  of  tears  and  nerves  which  we  doctors  call 
woman."  The  patient  walked  toward  him  and  said.  'T  came 
to  consult  Dr.  So-and-So,  and  not  to  hear  your  disrespectful 
expression  of  opinion  concerning  w^oman.    You  are  apparently 


54  THE   ENDOCRINES 

a  little  whipper-snapper.  Have  you  forgotten  that  a  woman 
brought  you  into  the  world  and  cared  for  you  for  years, 
gave  you  her  time  and  attention  and  probably  sacrificed  her 
health  worrying  over  just  such  evidences  of  lack  of  respect  as 
you  have  shown  to  me?"  The  next  day  when  she  came  by 
appointment  to  see  the  surgeon  himself,  the  young  doctor 
walked  into  the  waiting-room  and  said,  "Oh,  I  have  been 
looking  for  you  all  morning.  How  charming  you  look.  You 
certainly  do  wear  stylish  dresses,  and  that  coat  is  so  beautiful 
in  color."  Amazed  by  this  attempt  at  flattery  she  opened  her 
coat,  disclosing  a  red  lining,  and  said,  "Yes,  this  color  always 
does  make  parrots  talk." 

Now  in  the  many  circumstances  where  advice  and  en- 
couragement are  of  increasing  value  in  proportion  as  the  phy- 
sician has  the  respect  and  confidence  of  the  patient,  and  in  pro- 
portion as  the  patient  is  suggestible,  let  the  physician  remem- 
ber one  thing.  Let  his  relation  be  that  of  a  physician  and  a 
friend,  but  let  not  a  social  intimacy  develop.  Further,  any 
familiarity  which  passes  beyond  the  limits  of  proper  social 
dignity  and  the  exchange  of  dignified  courtesies  results  in  the 
loss  of  that  sense  of  awe  and  reverence  and  that  sense  of  respect 
which  should  be  felt  towards  the  physician. 

The  closer  the  social  intimacy  the  less  does  one  look  upon 
the  physician  as  a  man  of  medicine  and  the  more  does  he  ap- 
pear to  be  a  medical  man. 

Medical  men  are  not  without  this  failing ;  they  value  more 
highly  a  man  whose  work  they  have  read  and  studied  but 
whom  they  have  not  known.  People  who  grow  up  with  men 
of  their  own  age,  or  with  the  younger  generation,  and  know 
them,  can  never  have  quite  the  same  feeling  of  wonder  and 
respect  for  their  subsequent  attaintment  and  success  as  the 
young  have.  Parents  continue  to  look  upon  their  children  as 
children,  often  without  an  adequate  realization  of  their  men- 
tality and  ability.  However  much  a  physician  may  feel  that 
long  visits  and  interesting  conversations  take  the  patient's  mind 
off  her  troubles,  and  to  that  extent  benefit  her  mental  and 
psychic  state,  experience  will  teach  men  that  it  is  the  patient's 


ENVIRONMENT  AND  HEREDITY  55 

acting  on  his  advice  and  not  the  comfort  of  his  presence  that 
produces  lasting  results.  Otherwise  he  wastes  much  time,  it 
eventually  becomes  a  strain  on  his  nerves,  it  becomes  a  bur- 
den of  sameness  and  he  soon  realizes  that  it  is  his  presence  and 
not  his  mental  suggestions  which  the  patient,  without  knowing 
it,  desires.  And  if  there  is  anything  which  the  physician  should 
avoid,  it  is  the  faintest  suggestion  or  the  faintest  possibility 
of  the  triangle  which  forms  the  basis  for  so  many  novels  and 
so  many  plays. 


CHAPTER    III 

AN  INTRODUCTION  TO  THE  STORY  OF  THE 
ENDOCRINES 

The  influence  and  action  of  the  endocrine  glands  are  evi- 
denced by  somatic,  mental  and  psychic  changes.  If  we  can 
fathom  and  understand  what  the  ductless  glands  have  done 
to  an  individual  up  to  the  stage  of  puberty,  we  may  appreciate 
why  the  individual  develops  as  he  does.  If  we  can  reason  out 
what  these  ductless  glands  have  done  to  that  individual  from 
puberty  on,  we  may  understand  why  that  individual  is  what 
he  is  and  why  so  many  changes  have  occurred  in  him.  If  we 
can  eventually  fathom  what  hereditary  and  accidental  and  in- 
tercurrent factors  are  responsible  for  these  gland  changes  and 
for  the  consequent  somatic,  mental  and  psychic  factors,  then 
medicine  will  have  accomplished  a  glorious  work. 

You  naturally  expect  to  have  a  gynecologist  make  fre- 
quent reference  to  the  ovary  as  a  secretory  organ,  for  in  many 
ways  the  ovary  dominates  a  woman's  life  both  physical  and 
mental.  Whatever  may  be  one's  opinion  concerning  the  in- 
ternal secretion  or  secretions  of  the  ovary,  we  all  acknowledge 
the  ovum  to  be  its  external  product.  Fecundation  means  the 
union  of  a  ripe  ovum  and  an  active  spermatozoon. 

It  must  be  mentioned  that  the  germ-cells  have  been  set 
aside  early  in  the  embryonic  stage,  that  each  contains  the 
potentials  of  a  new  individual  who  may  some  day  result  from 
the  union  of  one  of  these  ova  with  a  spermatozoon  and  from 
the  union  of  the  chromosomes  of  their  nuclei, 

Mendelism  teaches  us  that  the  determiners  of  the  traits  of 
the  father  and  the  mother  are  brought  together  in  the  off- 
spring. When  the  male  pronucleus  has  united  with  the  female 
pronucleus,  in  each  chromosome  there  is  carried  the  determin- 
ers of  a  number  of  characters  instead  of  one.  Nothing  except 
creation  itself  is  so  wonderful  as  the  fact  that  these  microscopic 
chromosomes  contain  the  potentials  which  make  of  the  new 
being,  procreated  by  a  union  of  the  male  and  female  pronu- 

56 


AN  INTRODUCTION  TO  THE  STORY  OF  THE  ENDOCRINES      57 

cleus,  an  individual  who  resembles  his  parents  in  face  or  in 
form  or  in  characteristics ;  and  who  develops  in  himself  qual- 
ities transmitted  from  his  grandparents  and  his  forefathers. 

In  cell  division  the  nuclei  break  up  into  segments  which 
are  known  as  chromosomes.  Each  type  of  animal  has  a  par- 
ticular number  of  chromosomes  in  the  nucleus.  Before  ripen- 
ing, the  nuclei  of  the  conjugating  gametes  (ovum  and  sperma- 
tozoon) contain  only  one-half  of  the  usual  number  of  chromo- 
somes. The  chromosomes  have  united  in  pairs  instead  of  split- 
ting, and  one  part  of  each  pair  goes  into  the  new  ripening 
daughter  cells.  In  these  pairs  there  is  a  chromosome  of  ma- 
ternal origin  and  one  of  paternal  origin.  This  takes  place  in 
the  halving  which  occurs  at  maturation.  When  the  ovum  and 
the  spermatozoon  unite,  the  fecundated  ovum  then  crtntains 
double  this  halved  number  of  chromosomes  and  the  usual  num- 
ber is  restored  (Guyer). 

The  sex  chromosome  in  the  spermatozoon  does  not  divide. 
The  sex  chromosome  of  the  ovum  does.  This  sex  chromosome 
in  the  spermatozoon  thus  causes  an  uneven  number  of  chromo- 
somes before  halving,  hence  when  maturation  takes  place  some 
of  the  new  spermatozoa  have  the  sex  chromosome  and  others 
have  not.  It  is  this  sex  element  in  the  spermatozoon  which, 
when  uniting  with  the  female  sex  chromosome,  results  in  a 
female  child.  If  the  spermatozoon  contains  no  sex  chromo- 
some its  union  with  the  female  sex  chromosome  results  in  a 
male  child.  It  is  probable  that  the  sex  determiners  are  asso- 
ciated with  this  sex  chromosome  of  the  spermatozoon. 

We  know  that  dominants  and  recessives  determine  the 
character  of  the  new  being.  This  may  be  illustrated  by  fac- 
tors which  appeal  to  any  one.  For  instance,  as  to  the  eyes, 
brown  or  black  are  dominant  to  blue  or  gray.  As  to  the  color 
of  the  hair,  dark  is  dominant  to  light,  black  is  dominant  to  red. 
As  to  the  shape  of  the  hair,  curly  is  dominant  to  straight.  As 
to  the  skin,  dark  is  dominant  to  light.  As  to  temperament, 
nervous  is  dominant  to  phlegmatic. 

Through  the  action  of  the  dominants  and  recessives  we 
find  that  there  may  be  transmitted  color-blindness,  hemophilia. 


58  THE    ENDOCRINES 

myopia,  multiple  sclerosis,  muscular  atrophy,  ichthyosis,  web- 
finger,  albinism,  feeble-mindedness,  insanity.  Among  the  in- 
herited qualities  are  musical  ability,  literary  ability,  memory, 
ability  in  arithmetic,  mechanical  skill,  longevity,  handwriting, 
obesity,  muscular  strength  and  many  other  characteristics 
(Guyer). 

There  is  no  doubt  that  many  a  tendency  transmitted 
through  generations  must  depend  upon  a  transmitted  stability 
or  instability  of  one  or  more  of  the  internal  secretory  glands' 
functions.  We  recognize  in  innumerable  families  an  instability 
of  the  thyroid  transmitted  through  generations.  Hemophilia 
is  an  excellent  example  of  this  transmission  by  Mendellian 
law.  Dementia  precox  is  another.  I  myself  have  so  often  ob- 
served the  hereditary  nature  of  hypophysis  transmission  that 
I  could  cite  many  interesting  family  histories. 

Dercum  shows  that  dementia  precox  is  a  recessive  trans- 
mitted by  Mendellian  law.  In  dementia  precox  there  is  an 
affection  of  the  cortex  and  of  the  vegetative  nervous  system. 
The  toxins  act  on  the  autonomous  and  sympathetic  system, 
affecting  not  only  the  brain  but  the  circulation,  the  digestion 
and  the  pupillary  reaction.  This  explains  the  emotion  effects, 
for  these  are  expressions  through  the  sympathetic  nervous  sys- 
tem. Dercum  finds  that  the  internal  glands  are  involved  in 
dementia  precox.  The  sex  glands  may  dominate  the  picture, 
the  thyroid  may  be  the  important  element.  There  may  be  an 
involvement  of  the  pituitary  or  of  the  thyroid  or  of  the  adre- 
nals or  of  all  three  of  them.  Fauser  found,  in  the  serum  of 
dementia  precox  patients,  defensive  ferments  against  the  sex 
glands  and  the  cortex.  Hence  the  idea  that  unchanged  gonad 
proteins  enter  the  blood  and  cause  a  lysis  of  the  cortex.  He 
also  finds  defensive  ferments  against  the  thyroid,  adrenals 
and  thymus. 

Now  that  we  know  the  important  relation  existing  be- 
tween the  various  secretory  glands,  and  among  these  the  ovary 
and  the  testicle  are  not  the  least  important,  we  can  understand 
that  in  dementia  precox  menstruation  is  delayed  or  that  there 
is  sexual  precocity,  for  menstruation  is  a  pluriglandular  cyclic 


AN  INTRODUCTION  TO  THE  STORY  OF  THE  ENDOCRINES       i>9 

process.  We  can  understand  sexual  excesses,  vagaries  and 
perversions.  It  is  easily  understood  why  the  symptoms  are 
brought  out  or  accentuated  by  menstruation  or  brought  on 
by  pregnancy,  repeated  pregnancy,  or  by  miscarriage.  Hence 
dementia  precox  is  a  serious  and  extreme  type  of  endocrine 
aberration  or  abnormality  evidencing  its  presence  by  psychic 
rather  than  somatic  alterations.  So  as  we  delve  into  one  men- 
tal aberration  after  another,  the  internal  secretory  glands  seem 
to  be  more  and  more  related  to  conditions  characterized  by 
psychic  manifestations. 

The  physical  and  mental  development  of  the  individual 
are  dependent  on  the  action  and  interaction  of  the  ductless 
glands.  The  nutrition  of  the  body,  of  the  mind  and  of  the 
sex  organs,  as  we  are  learning  more  and  more,  are  dependent 
on  the  trophic  stimuli  of  the  ductless  gland  system.  Long 
before  the  trophic  relation  between  the  various  glands  and 
the  ovary  is  evidenced  by  menstruation  and  development  of 
the  secondary  sex  characteristics,  these  glands  are  concerned 
with  the  body  growth. 

The  physical  and  mental  development  of  a  growing  child 
is  dependent  upon  the  activity  of  the  hypophysis  gland  and 
particularly  the  thyroid  gland.  Bony  growth  is  of  course  re- 
lated to  calcium  metabolism  and  here  the  thymus  and  the  para- 
thyroids and  adrenals  are  of  importance.  The  thymus  and 
the  parathyroid  glands  are  particularly  concerned  with  calcium 
metabolism  and,  to  this  degree  and  probably  in  ways  which 
we  do  not  yet  understand,  they  are  intimately  associated  there- 
fore with  bony  growth  and  the  development  of  the  skeleton. 
We  do  know  that  hypothymism  causes  short  bones,  thin  bones^ 
fragile  bones.  We  know  the  lack  of  physical  and  mental  de- 
velopment in  cretinism.  We  know  that  dwarfs  may  also  be 
due  to  an  underactivity  of  the  hypophysis  gland. 

In  hypopituitarism,  if  there  is  a  diminished  function  of  the 
posterior  lobe  before  puberty,  and  a  consequent  failure  of 
stimulation  of  the  uterus  and  ovaries,  we  have  a  resulting 
sexual  infantilism  and  an  absence  of  menstruation.  In  the 
type  of  Froelich  we  observe  a  failure  of  skeletal  and  sexual 


60  THE    ENDOCRINES 

development.  If  hypopituitarism  of  the  posterior  lobe  occur 
after  adolescence,  genital  dystrophy  results,  that  is,  a  degen- 
eratio  adiposo genitalis. 

On  the  other  hand  no  excessive  action  of  the  thyroid  will 
produce  a  giant,  but  excessive  action  of  the  hypophysis  gland, 
particularly  the  anterior  lobe,  does  produce  normal  giants  and 
in  excessive  cases  such  giants  as  we  see  in  the  circus. 

The  adrenals  are  developed  from  the  same  region  as  the 
ovary,  in  fact  they  both  come  from  what  is  known  in  em- 
bryology as  the  genital  ridge.  The  thyroid  in  addition  to  its 
numerous  stimulating  and  protective  functions  is  distinctly  a 
sex  gland,  particularly  so  in  the  female,  as  may  be  recognized 
from  the  fact  that  thyroid  diseases  are  from  six  to  eight  times 
as  frequent  in  the  female  as  in  the  male. 

The  attention  of  every  one  is  called  to  the  sex  activity  of 
the  pituitary  gland  because  of  the  well-known  action  of  pitui- 
trin  in  labor,  Early  development  of  the  body  with  sexual 
precocity  may  be  due  to  an  involvement  of  the  hypophysis 
gland,  of  the  adrenals  or  of  the  pineal  gland  or  of  the  testis. 
Cases  of  this  type  with  tumor  throw  a  decided  light  on  the 
relation  of  these  glands  in  the  way  of  over  or  underactivity  to 
the  physical,  mental  and  sexual  development  of  the  growing 
child.  The  difference  in  the  skeleton  of  the  female  and  the 
male,  the  difference  in  the  shape  of  the  pelvis,  the  larger  hands 
and  feet  in  the  male  show  to  us  that  in  the  tzvo  sexes  bony 
growth  must  he  modified  to  a  certain  degree  by  the  action  of 
the  ovaries  on  the  one  side  and  the  testes  on  the  other  side. 
Our  attention  here  must  be  given  particularly  to  the  hypophysis 
gland. 

Let  us  see  in  what  way  its  activity  is  modified  by  the  fact 
that  the  female  has  an  ovary  and  the  male  has  the  testis. 
Practically  all  the  glands  of  the  body  are  concerned  in  physical 
development,  in  the  development  of  the  bones  and  in  the  mental 
phase  of  development. 

The  physical  build  and  the  secondary  sex  characteristics 
of  the  male  and  the  female  differ  to  a  decided  degree.  It  is 
impossible  to  conceive  of  two  glands  so  different  in  their  action 


AN  INTRODUCTION  TO  THE  STORY  OF  THE  ENDOCRINES      61 

as  the  ovaries  and  the  testes  without  coming  quickly  to  the 
conclusion  that  they  must  modify  in  a  decided  degree  the  rela- 
tion which  the  other  three  glands  bear  to  them,  referring  here 
again  to  the  thyroid,  the  hypophysis  and  the  adrenals.  The 
question  may  be  answered  at  first  hand  by  the  statement  that 
the  ovary  has  an  effect  on  the  female  and  the  testis  has  a 
specific  effect  on  the  male.  But  their  action  is  in  all  probability 
not  one  exerted  entirely  per  se,  but  due  to  an  action  stimu- 
lated or  inhibited  in  the  other  glands,  that  is,  the  interactivity 
or  activity  of  the  other  ghi)ids  is  altered. 

The  interstitial  cells  of  Leydig  in  the  testis  are  intimately 
concerned  with  the  changes  which  produce  the  bony  growth 
and  the  male  secondary  sex  characteristics.  They  are  related 
not  only  to  the  heavier  bone  development,  the  shape  of  the  male 
pelvis,  but  also  to  the  growth  of  hair  and  beard,  the  more  gen- 
erous distribution  of  hair  and  changes  in  the  voice. 

Changes  of  an  entirely  different  nature  occur  in  the  fe- 
male. \\q  have  the  smoother  skin,  the  lesser  distribution  of 
hair,  the  absence  of  hair  on  the  face,  the  difference  in  the  voice, 
a  more  generous  layer  of  fat  under  the  skin,  a  development  of 
the  nates  and  the  typical  shape  of  the  female  pelvis. 

The  testis  in  the  male  produces  such  a  change  in  the 
adrenals,  in  the  pineal  and  in  the  hypophysis  that  by  its  own 
action  and  by  its  stimulation  of  these  other  glands,  the  charac- 
teristic qualities  of  the  male  are  produced.  It  seems  as  if  this 
type  of  function  in  the  hypophysis  were  more  active  in  the  male 
than  in  the  female.  This  gland  has  much  to  do  with  the 
growth  of  hair  and  with  the  character  of  the  bkin  and  with  the 
bony  framework.  In  other  words,  the  anterior  lobe  of  the 
hypophysis  is  more  a  male  than  a  female  gland  and  the 
posterior  lobe  is  more  a  female  than  a  male  gland.  So  with 
the  thyroid,  which  is  more  of  a  sex  gland  especially  in  the 
female  than  is  generally  appreciated.  The  ovary  does  not 
stimulate  the  anterior  hypophysis  and  the  adrenal  cortex  to 
the  same  degree  as  the  testis  does.  There  is  less  stimulation 
or  a  relatively  slight  inhibiting  action  on  the  hypophysis  by 
the  ovary  which  results  in  a  different  distribution  of  hair  with 


62  THE    ENDOCRINES 

lighter  and  more  gracile  skeleton,  small  hands,  smooth  skin. 
This  speaks  for  a  certain  degree  of  antagonism  in  this  specific 
phase,  between  ovary  and  hypophysis.  Another  evidence  of 
inhibition  seems  to  be  introduced  by  early  ripening  of  the 
ovaries. 

The  thymus  gland  is  supposed  to  have  an  inhibiting  effect 
on  the  gonads,  preventing  their  too  early  development.  At  the 
proper  tim^  the  thymus  and  the  pineal  are  supposed  to  regress 
and  the  inhibiting  influence  on  the  development  of  the  gonads 
being  removed,  the  latter  come  into  their  function  at  the  normal 
time  and  in  the  proper  way.  A  prolonged  action  on  the  part 
of  the  thymus  inhibits  the  early  development  of  the  gonads; 
a  too  early  regression  of  the  thymus  favors  their  early  function. 
This  action  of  the  pineal  and  thymus  seems  to  be  more  pro- 
nounced and  frequent  in  the  male  than  in  the  female. 

Early  ripening  of  the  ovary  often  has  an  effect  on  skeletal 
growth,  resulting  in  sHghter  stature  with  short  legs,  whereas 
late  maturation  of  the  ovary  results  in  a  larger  individual.  The 
relation  of  the  ovary  to  calcium  metabolism  may  be  further  ob- 
served by  the  fact  that  excessive  action  of  the  ovaries  may 
abnormally  increase  the  calcium  output.  The  condition  known 
as  osteomalacia  is  to  be  considered  as  an  example.  So  far  as 
the  ovaries  are  concerned  we  are  as  yet  by  no  means  settled 
as  to  the  various  elements  contained  therein.  All  the  elements 
of  the  ovary  promote  uterine  hyperemia.  Extract  of  the  inter- 
follicular  tissue  and  of  the  hilus  diminish  contractility  of  the 
uterine  muscle  and  of  all  muscle  fibers  when  immersed  in  these 
fluids.  This  extract  likewise  diminishes  the  coagulability  of 
the  blood.  Injection  of  tissue-juice,  experimentally  carried  out, 
injures  the  follicles. 

The  liquor  follicuH,  extract  of  the  follicle  lining  and  cor- 
pus luteum  increase  the  contractility  of  uterine  muscle  and  of 
all  muscle  fibers  when  immersed  in  these  fluids.  Corpus  luteum 
increases  the  coagulability  of  the  blood.  The  injection  of  cor- 
pus luteum  into  the  veins  causes  thromboses.  Corpus  luteum 
dilates  the  cerebral  vessels. 


AN  INTRODUCTION  TO  THE  STORY  OF  THE  ENDOCRINES      63 

We  distinguish  the  granulosa  lutein  and  the  theca  lutein. 
This  latter  so-called  interstitial  structure  is  said  to  be  respon- 
sible for  the  secondary  sex  characteristics  in  the  female  as 
the  interstitial  cells  of  Leydig  are  said  to  be  responsible  for  the 
secondary  sex  characteristics  in  the  male.  If  so,  this  interstitial 
substance  may  have  an  inhibitory  effect  on  the  hypophysis  an- 
terior lobe.  It  is  claimed  by  Schafer  and  others  that 
menstruation  is  due  to  this  element  of  the  ovary  and  not 
to  the  follicles  or  to  the  corpus  luteum.  These  theca  cells 
are  derived  from  the  stroma  and  not  improbably  from 
the  interstitial  cells  (Schafer).  It  is  claimed  by  some  that 
the  corpus  luteum  is  developed  from  stroma  cells.  Others 
hold  that  the  luteal  cells,  at  least  in  part,  are  derived  from  the 
epithelium  which  originally  lined  the  follicle.  While  all  the 
elements  of  the  ovary  promote  uterine  hyperemia  and  hy- 
peremia of  the  external  genitalia,  there  are  two  hormones  in 
the  ovary,  one  which  prevents  or  diminishes  contraction,  while 
the  other  contracts  muscle,  excites  it  or  renders  it  sensitive  to 
contractile  stimuli. 

The  possession  by  the  ovary  of  hormones  having  an  op- 
posite action  is  paralleled  in  the  pituitary  body  which  contains 
hormones  having  totally  different  effects  on  different  struc- 
tures in  the  body  and  at  least  two  hormones  which  are  oppo- 
site in  their  effects,  as  may  be  seen  from  the  following :  Pitui- 
trin  comes  from  pars  nervosa  and  pars  intermedia  of  which 
the  pars  nervosa  acts  upon  the  blood-vessels.  Its  action  on  the 
blood-vessels  is  a  direct  one  and  not  due,  as  the  suprarenals, 
to  a  stimulative  action  on  the  sympathetic  nervous  system. 
While  pituitrin  contracts  the  blood-vessels  in  general,  the  kid- 
ney vessels  on  the  other  hand  undergo  dilatation  and  the  kid- 
ney cells  themselves  are  stimulated  directly.  The  diuretic 
action  of  the  pituitary  is  not  antagonized  by  atropine.  The 
posterior  lobe  of  the  pituitary  yields  more  than  one  autocoid. 
A  specific  hormone  affects  the  secretion  of  milk,  quite  possibly 
the  effect  upon  the  uterus  is  due  to  another,  while  there  is  little 
doubt  that  the  fall  of  blood-pressure  produced  by  a  second  dose 
of  pituitary  extract  is  due  to  a  chalonic  agent  entirely  different 


64  THE   ENDOCRINES 

from  the  hormone  which  causes  the  initial  rise.  There  is,  how- 
.  ever,  no  tachyphylaxis  as  regards  the  effects  on  the  uterus. 
There  is  no  tachyphylaxis  as  regards  its  effect  upon  the  kid- 
ney. There  are  two  autocoids  opposed  in  their  effects  which 
act  upon  intestinal  muscle,  one  producing  inhibition  and  the 
other  contraction  (Schafer). 

Before  menstruation  develops,  however,  the  shape  of  the 
female  pelvis  is  advanced  in  its  development  and  we  have 
credited  to  the  ovarian  secretion  in  the  earlier  years  a  definite 
relation  to  the  hypophysis  and  other  glands,  of  a  somewhat  in- 
hibitory character  as  regards  the  anterior  lobe  of  the  latter  par- 
ticularly, compared  with  the  action  of  these  glands  zvhen  in- 
fluenced by  the  testes.  This  inhibition  is  more  marked  still 
after  menstruation  develops.  When  menstruation  develops 
the  corpus  luteum  is  normally  developing  each  month,  coming 
into  play  with  other  glands,  and  thus  we  have  a  relatively 
new  secretion,  a  secretion  both  inhibitory  and  stimulative  to 
the  hypophysis,  thrust  into  the  economy.  Therefore  thir- 
teen times  each  year  in  normal  cases  there  develops  in  one 
ovary  or  the  other,  a  corpus  luteum  which  is  a  gland  of  marked 
secretory  influence.  This  reacts  upon  the  thyroid  and  the 
posterior  hypophysis  particularly.  It  stimulates  the  thyroid 
in  anticipation  of  pregnancy;  it  should  inhibit  the  posterior 
pituitary  to  avoid  uterine  contractions.  There  is  no  question  in 
my  mind  that  the  posterior  lobe  of  tlT£  hypophysis  is  intimately 
connected  with  menstruation  and  that  the  ovaries  and  the  pos- 
terior lobe  of  the  pituitary  have  trophic  control  over  the  zvell- 
being  of  the  uterus  and  the  adnexa.  The  uterine  lining  swells 
each  month  into  the  menstrual  decidua,  producing  a  secretion 
which  reacts  on  the  ovary.  Ovarian  secretion  and  the  corpus 
luteum  react  upon  the  decidua.  At  menstruation  blood  is 
thrown  off  and  a  stimulus  by  the  posterior  lobe  of  the  pituitary 
is  undoubtedly  exerted.  In  all  probability  many  cases  of  ex- 
cessive pain  and  uterine  contractions  during  menstruation  re- 
sulting in  dysmenorrhea  are  due  to  excessive  activity  of  the 
posterior  lobe  at  these  menstrual  epochs  aided  by  the  action 
of  corpus  luteum. 


AN  INTRODUCTION  TO  THE  STORY  OF  THE  ENDOCRINES      65 

It  is  interesting  to  note  the  influence  of  the  premenstrual 
stage.  On  questioning  patients  as  to  the  symptoms  by  which 
they  recognize  the  onset  of  the  expected  menstruation,  one 
notes  that  there  is  no  warning  in  many.  In  others  there  is  a 
slight  fullness  of  the  breasts,  in  others  a  sensation  of  weight 
in  the  pelvis,  in  others  there  may  be  backache,  others  have 
slight  pains  a  day  or  two  before  menstruation.  However,  a 
goodly  number  of  patients  note  the  approach  of  the  next  ex- 
pected menstruation  by  the  onset  of  nervous  symptoms.  Some 
are  depressed  markedly,  others  are  irritated.  Many  become  so 
nervous  in  the  few  days  before  menstruation  that  a  marked 
interglandular  instability  is  certain.  They  are  irritable,  rest- 
less, cry  easily,  some  are  alternately  depressed  and  excited, 
giving  rise  to  what  I  have  termed  constitutional  dysmenorrhea. 

When  we  realize  the  influence  of  the  ovarian  secretion 
and  the  corpus  luteum  with  its  tendency  to  dilate  the  cerebral 
vessels,  when  we  take  into  consideration  the  swelling  of  the 
thyroid  with  a  probability  of  actual  hyperthyroidism  being 
present  in  many  cases,  when  we  consider  that  changes  take 
place  in  the  hypophysis  gland,  particularly  the  posterior  lobe 
at  menstruation,  we  may  realize  how  a  sensitive  or  unstable 
relation  of  these  three  glands  may  cause  patients  to  suffer  for 
the  few  days  before  each  menstruation,  and  this  apart  from 
the  distress  of  dysmenorrhea.  Dysmenorrhea,  amenorrhea 
and  menorrhagia  may  he  the  somatic  evidences  of  endocrine 
abnormality.  Constitutional  dysmenorrhea  is  the  psychic  evi- 
dence of  this  abnormality  or  instability. 

Menstruation  is  a  miniature  labor,  labor  is  a  magnified 
menstruation.  The  hypophysis  reacts  at  menstruation  in  the 
same  way  that  the  thyroid  does  and  the  posterior  lobe  par- 
ticularly is  closely  concerned  with  the  menstrual  function.  At 
full  term  we  have  the  ovary  and  the  pituitary  extract  acting 
again  as  they  do  at  menstruation  after  a  period  of  two  hundred 
and  eighty  days,  during  which  time  their  menstrual  function 
has  been  inhibited  by  the  presence  in  the  uterus  of  the  placental 
gland.  At  the  menopause  or  change  of  life  period  we  have  a 
regression  of  the  ovarian  function  with  a  coincident  alteration, 


66  THE    ENDOCRINES 

in  normal  cases,  on  the  part  of  the  thyroid,  adrenals  and  altera- 
tions on  the  part  of  the  hypophysis. 

Since  every  ductless  gland  is  influenced  by  hyperactivity 
or  hypoactivity  of  any  of  the  other  glands  in  the  cycle,  it  can 
be  readily  seen  why  we  have  instability  of  gland  function  so 
particularly  marked  in  the  female.  Hence  the  thyroid  and 
hypophysis  are  being  played  upon  thirteen  times  each  year  by 
the  menstrual  function.  These  glands  are  affected  and  marked- 
ly so  by  pregnancy,  miscarriage  and  by  labor.  In  pregnancy 
the  anterior  lobe  of  the  hypophysis  evidences  increased  activity, 
the  gland  finally  becoming  larger  and  remaining  thereafter 
always  somewhat  enlarged. 

Since  the  entire  coordination  between  the  glands  is  often 
upset  at  the  menopause  period  we  can  readily  account  for  the 
nervous  phenomena  so  frequent  in  the  female;  for  it  requires 
only  a  slight  study  to  determine  that  the  thyroid,  adrenals  and 
the  hypophysis  are  very  essential  to  a  normal,  stable  nervous 
system  and  normal  cerebral  activity.  If  we  as  gynecologists 
lay  great  stress  on  the  importance  of  ovarian  function  it  is 
because  the  function  of  the  ovary,  as  manifested  by  menstrua- 
tion and  premenstrual  symptoms  particularly,  is  an  index  to 
its  relation  to  other  glands  and  to  the  element  of  acquired  or 
inherited  instability. 

In  some  instances  of  ovarian  instability  hyperfunction  or 
hypofunction  may  be  primary,  but  in  very  many  instances  its 
relation  to  the  thymus,  thyroid  and  the  hypophysis  is  so  close 
that  the  result  is  secondary.  From  whichever  point  we  ap- 
proach this  question,  it  may  be  stated  that  altered  ovarian 
function  as  evidenced  by  menstruation,  is  an  index  and  an  evi- 
dence that  there  is  an  upset  somewhere  in  the  endocrine  chain. 

The  thymus  acts  on  the  growth  of  bone  as  does  the  thy- 
roid. In  underfunction  of  the  thymus  the  bones  are  shorter, 
thinner  and  more  fragile.  Early  retrogression  of  the  thymus 
results  in  large  hyperplastic  ovaries.  Hypoplastic  ovaries  may 
indicate  a  persistent  thymus. 

The  relationship  of  the  thymus  to.  the  testis  seems  to  be 
more  marked  than  the  relationship  between  thymus  and  ovary. 


AN  INTRODUCTION  TO  THE  STORY  OF  THE  ENDOCRINES       67 

It  is  possible  that  in  some  cases  hypoplastic  ovaries  may  be 
related  to  the  status  thymicus  where  we  find  the  large  thymus, 
the  large  lymph  glands,  large  tonsils  and  follicles  at  the  base 
of  the  tongue,  a  narrow  aorta  and  a  large  pale  heart.  In  this 
connection  it  may  be  mentioned  that  this  type  of  case  is  asso- 
ciated with  suprarenal  insufficiency.  The  status  thymicus  is 
not  infrequently  associated  with  Graves'  disease  and  the  opin- 
ion has  been  expressed  that  Graves'  disease  may  represent  a 
hyperthymus  state.  Hence  the  diminished  menstruation  in 
many  cases  of  Graves'  disease. 

With  hypoplasia  of  the  ovaries  the  uterus  develops  poorly. 
Menstruation  is  diminished,  delayed  or  absent,  and  the  sec- 
ondary sex  characteristics  are  less  well  marked.  The  repro- 
ductive function  of  the  female  may  not  be  impaired  even  if 
sex  characteristics  are  wanting.  Trichosis  of  the  male  type 
may  be  manifest,  which  again  speaks  for  a  removal  of  the 
inhibition  of  the  anterior  lobe  and  adrenal  cortex  which  we 
have  mentioned  as  one  of  the  functions  of  the  normal  ovary. 

Infantile  uterus,  hypoplasia  of  the  uterus  and  adnexa, 
poorly  developed  secondary  sex  characteristics,  late  men- 
struation are  an  evidence  either  of  primary  involvement  of 
the  ovaries  and  genital  tract,  or  a  secondary  influence  exerted 
upon  them  by  the  thyroid,  hypophysis,  adrenals,  thymus  or 
other  glands. 

Each  case  must  then  be  studied  to  determine  the  primary 
condition.  Whatever  condition  be  the  cause,  stimulation  of 
the  ovaries  and  of  the  genital  tract  by  the  administration  of 
ovarian  extract  and  ovarian  residue  is  essential  whether  thyroid 
or  hypophysis  be  given. 

The  amenorrhea  of  lactation  associated  with  lactation 
atrophy  is  due  to  the  influence  of  the  mammary  gland  secre- 
tion. The  mammary  gland  under  the  stimulus  of  nursing, 
elaborates  the  hormone  which  contracts  the  uterus  and  an- 
tagonizes ovarian  activity;  and  excessive  action  of  this  type 
associated  with  amenorrhea,  eventually  results  in  an  atrophy  of 
the  uterus  and  an  inhibition  of  ovarian  function  which  in  the 
huge  majority  of  cases  can  be  readily  overcome  by  the  ad- 


68  THE    ENDOCRINES 

ministration  of  ovarian  extract  or  ovarian  residue,  particularly 
if  iron,  arsenic  and  thyroid  be  added. 

Chlorosis  is  so  much  a  disease  of  the  adolescent  stage,  so 
almost  inevitably  found  in  girls,  that  the  good  results  of 
ovarian  extract  or  ovarian  residue  extract  when  used  here  and 
supplemented  with  iron  and  arsenic  can  be  readily  appreciated. 

A  decided  atrophy  of  the  uterus  which  occurs  occasionally 
after  a  too  thorough  curettage,  can  be  understood  when  we 
realize  that  the  endometrium  stimulates  the  ovary  and  the 
ovary  stimluates  the  endometrium;  and  if  too  thorough  a 
curetting  be  done  and  the  stimulation  exerted  on  the  ovary 
and  follicles  be  lost,  we  get  an  atrophy  of  the  uterus  which  in 
some  cases  is  hard  to  overcome,  particularly  if  in  these  cases 
there  exists  an  underfunction  of  the  posterior  lobe  of  the  pitui- 
tary and  its  nutritional  value  is  lost  or  if  there  is  dyspituitarism. 

In  young  women  with  constantly  accumulating  obesity 
there  occurs  very  often  a  diminution  of  the  ovarian  function 
and  of  menstruation,  with  an  atrophy  of  the  uterus  and 
ovaries  which,  in  many  cases,  no  method  of  treatment  will 
overcome.  Here  we  are  dealing  with  various  grades  of  what 
is  known  as  degeneratio-adiposo genitalis,  a  condition  due  to 
an  underfunctioning  of  the  posterior  lobe  of  the  pituitary  gland 
after  adolescence.  Here  the  endometrium  and  ovary  lose  the 
stimulus  necessary  to  their  activity,  the  uterus  loses  the  auto- 
massage  produced  by  the  pituitary  gland.  In  many  instances 
even  large  doses  of  ovarian  extract  or  thyroid  extract  supple- 
mented by  hypophysis  extract  are  of  little  avail.  However,  in 
all  cases  of  diminishing  menstruation,  extracts  of  the  ovary 
are  indicated.  This  may  seem  very  simple  as  a  general  prop- 
osition but  when  we  analyze  it  we  find  it  is  because  the  other 
glands  too  are  affected  thereby  that  this  ovarian  therapy  in 
the  field  of  nervous  and  mental  diseases  is  so  marked. 

In  acromegaly,  a  diminution  of  ovarian  and  uterine  func- 
tion, a  diminution  in  menstruation,  impotence  on  the  part  of  the 
male  are  so  marked  that  it  is  almost  a  temptation  to  agree  with 
some  of  the  foreign  authors  that  the  primary  disease  is  some- 
times located  in  the  gonads. 


AN  INTRODUCTION  TO  THE  STORY  OF  THE  ENDOCRINES       69 

//  the  hypophysis  and  its  diseases  act  on  the  ovaries  as  is 
the  case  in  acromegaly,  in  hypopituitarism  and  dyspituitarism, 
zvhy  may  not  the  reverse  he  true?  If  the  ovaries  are  affected 
by  the  infectious  diseases  of  childhood  or  by  the  diseases  and 
infections  of  adult  life,  and  a  hypoovarianism  results,  why 
may  we  not  get  a  lack  of  inhibition  of  the  anterior  lobe  and  a 
lack  of  stimulation  of  the  posterior  lobe  of  the  hypophysis? 
The  former  would  then  give  us  the  male  type  of  pelvis, 
the  male  form  of  trichosis,  and  from  this  point  on  the  various 
grades  of  increased  activity  of  the  anterior  lobe.  The  latter 
would  give  us  the  tendency  to  obesity  and  the  high  sugar  toler- 
ance and  the  various  gradations  of  posterior  lobe  insufficiency. 

//  the  thymus  inhibits  the  ovaries  zvhy  may  not  the  reverse 
he  true?  Then  the  infectious  diseases  of  children  or  a  pri- 
mary involvement  of  the  ovaries  by  making  them  hypoplastic 
would  result  in  a  persistent  thymus  and  a  tendency  to  the 
status  thymicus.  If  mumps,  for  instance,  may  result  in  an 
involvement  of  the  testicle,  the  same  effect  may  be  produced 
unrecognized  in  the  ovaries,  and  I  have  recognized  several  such 
cases. 

//  hyperthyroidism,  ivith  or  ztnthout  hypertJiymism^  is  so 
frequently  associated  zuith  diminished  ovarian  function  and 
ditninished  menstruation,  zuhy  may  not  the  reverse  be  true? 
Why  may  not  ovaries  hypoplastic  or  affected  by  infectious  or 
hypoactive  through  lack  of  proper  stimulation  result  in  rela- 
tive hyperfunction  of  the  thyroid  with  many  of  the  symp- 
tons  of  Graves'  disease  minus  the  exophthalmos  and  the 
goitre?  Why  may  not  ovaries  inefficient  as  to  their  secre- 
tion, due  to  lactation  or  to  so-called  small  cystic  degeneration, 
associated  with  diminished  menstruation  cause  a  condition  of 
relative  hyperthyroidism?  We  know  that  persistent  corpora 
lutea  do  cause  hyperthyroidism. 

In  the  climacterium,  especially  with  rapid  diminution  in 
ovarian  function,  a  state  of  relative  hyperthyroidism  is  of 
frequent  occurrence.  This  parallels  the  important  question  of 
primary  ovarian  involvement  after  puberty,  especially  the 
changes   connected   with  abortion,  pregnancy  and  labor  and 


70  ^  THE    ENDOCRINES 

inflammations.  The  latter,  particularly,  results  in  changes  in 
the  tunica  albuginea  and  in  the  retention  of  numerous  follicle 
cysts.  Ovarian  function  is  disturbed,  evidenced  somatically 
most  often  by  excessive  menstruation,  but  often  enough  by 
diminished  menstruation.  With  or  without  such  changes  we 
must  count  on  this  altered  ovarian  function,  either  excessive 
or  diminished,  as  having  a  direct  connection  with  those  glands 
most  intimately  associated  with  the  gonads.  The  balance  of 
the  endocrine  cycle  may  be  upset,  particularly  so  in  the  un- 
stable cases.  Instability  or  lability  is  thus  first  brought  to 
our  attention.  Hence  the  nature  of  the  interglandular  mani- 
festations are  various  in  type  and  form,  conforming  to  no 
definite  course  and  picture.  The  symptoms  may  be  purely 
somatic.     They  are,  however,  often  enough  psychic. 

Now  we  come  to  the  opposite  extreme,  overactivity  on 
the  part  of  the  ovaries,  evidenced  by  menorrhagia  or  metror- 
rhagia. Here  we  find  greater  difficulty  in  accomplishing  a 
therapeutic  result.  Novak  finds  that  corpora  lutea  with  marked 
development  of  the  paralutein  tissue  often  are  associated  with 
excessive  menstruation.  The  degree  of  uterine  bleeding  is 
not  related  to  the  amount  of  lutein  tissue  found  in  the  respec- 
tive ovary.  Whereas  the  ovarian  extract  or  ovarian  residue 
helps  in  cases  of  hyperthyroidism,  thyroid  does  not  do  so 
much  for  the  cases  of  hyperovarianism.  We  must  look  to 
other  glands.  The  mammary  gland  extract  is  an  excellent 
thing  in  many  cases  of  menorrhagia  because  of  its  well-known 
action  as  evidenced  by  lactation  atrophy.  Nursing  tends  to 
inhibit  ovulation,  the  purpose  being  to  avoid  menstruation  and 
intercurrent  pregnancy.  The  thyroid  helps  in  some  cases  of 
menorrhagia,  especially  in  those  cases  due  to  an  undersection, 
a  relative  state  of  myxedema. 

Since  the  thymus  is  antagonistic  to  the  ovary,  it  would 
seem  to  be  of  value  for  ovarian  hyperactivity,  for  overgrown 
endometrium,  for  masturbation  and  for  menorrhagia.  I  note 
that  this  extract  has  received  little  attention  for  this  indication 
and  yet  it  has  proven  in  my  hands  to  be  exceptionally  valuable 
in  the  persistent  menorrhagia  of  young  girls,  when  all  other 


AN  INTRODUCTION  TO  THE  STORY  OF  THE  ENDOCRINES       71 

drugs  or  extracts  have  failed.  In  the  persistent  menorrhagia 
and  metrorrhagia  which  occasionally  follows  the  ideal  vaginal 
operation  for  prolapse  of  the  uterus  it  has  served  me  well.  In 
the  persistent  bleeding  associated  with  fibrosis  uteri  it  is  oc- 
casionally effective  when  used  in  combination  with  ergot  or 
ergotine  and  mammary  extract. 

Recently  our  attention  is  being  attracted  to  the  value  of 
placental  gland  extract  in  cases  of  menorrhagia  and  metror- 
rhagia. Theoretically  it  would  seem  to  be  the  proper  thing  to 
use,  because  the  moment  that  pregnancy  takes  place,  the  se- 
cretion from  the  outer  covering  of  the  ovum  inhibits  the  men- 
strual stimulus  produced  by  the  ovary,  adrenals  and  the  pos- 
terior lobe  of  the  pituitary  gland.  During  pregnancy  there 
is  antagonism  as  to  menstruation  between  the  pituitary,  ovary 
and  adrenals  on  the  one  side  and  the  corpus  luteum.  thyroid 
and  placenta  on  the  other. 

I  should  like  to  discuss  what  I  have  called  .  .  .  The 
higher  up  theory  of  sterility  ...  I  do  not  want  to  decry 
the  operation  of  dilatation  of  the  cervix  or  discision  or  any 
other  method  of  cervical  operation  for  sterility,  but  I  feel  that 
we  have  spent  entirely  too  much  time  at  this  point  of  attack 
and  have  concentrated  our  thoughts  on  the  area  which  is  not 
at  all  responsible  in  a  large  proportion  of  cases. 

One  might  safely  say  that  it  is  hard  to  keep  a  good  sper- 
matozoon from  passing  through  the  cervix  and  it  is  very  hard 
for  a  poor  spermatozoon  to  pass  upward  even  through  a  roomy 
cervix.  Spermatozoa  pass  upward  from  their  own  motility,  pos- 
sibly a  form  of  attraction  is  responsible  for  this  upward  move- 
ment. The  fact  is  that  the  ciliated  epithelium  acts  downward 
and  creates  a  current  against  which  they  move,  and  it  is  pos- 
sible that  their  inclination  is  to  move  against  the  current.  They 
pass  out  from  the  uterus  into  the  Fallopian  tubes.  Anyone 
who  has  seen  the  lumen  of  a  Fallopian  tube  at  the  interstitial 
area,  the  part  passing  through  the  horn  of  the  uterus,  knows 
how  extremely  narrow  this  area  is.  Therefore  a  spermatozoon 
that  can  pass  through  a  Fallopian  tube  of  this  sort  ought  to  be 


72  THE    ENDOCRINES 

able  and  ought  to  pass  up  through  any  stenosis  of  the  non- 
catarrhal  cervix. 

The  Hning  of  the  uterus  may  not  be  adapted  to  the  em- 
bedding of  an  ovum.  Its  character  may  be  so  altered  by  se- 
cretion or  some  other  condition  that  an  ovum  cannot  imbed 
itself  or  if  it  does  is  expelled  very  early.  We  have  a  large 
proportion  of  cases  in  which  spermatozoa  are  present  in  the 
partner  in  whom  no  cervical  or  uterine  inflammation  is  to  be 
found. 

Granted  that  the  spermatozoa  are  active  and  can  pass 
upward,  the  most  essential  feature  for  fecundation  is  the  pro- 
duction by  the  ovaries  of  ova  capable  of  fecundation  and  then 
of  passing  into  the  uterus  by  the  action  of  the  ciliated 
epithelium  of  the  tubes.  It  is  not  generally  recognized  that 
the  ciliated  epithelium  of  the  tubes  is  and  must  be  under  the 
trophic  control  of  the  ovaries,  probably  of  the  thyroid  and  very 
probably  of  the  pituitary  gland.  One  will  be  surprised  at 
operation  in  sterile  women  and  in  cases  of  one  child  sterility, 
to  see  the  atrophic  state  of  the  Fallopian  tubes,  slight,  thin, 
deprived  of  their  musculature.  In  all  probability  the  ciliated 
epithelium  does  not  act.  This  condition  is  undoubtedly  re- 
sponsible in  many  instances  for  sterility,  especially  that  type  of 
sterility  where  patients  have  for  years  and  years  been  sterile, 
and  finally  with  treatment  and  more  frequently  without  treat- 
ment become  pregnant. 

Associated  with  this  condition,  and  very  frequently  they 
go  hand  in  hand,  is  a  condition  in  the  ovary  where  ovulation 
in  the  strict  sense  does  not  take  place;  that  is  ova  are  not 
thrown  out.  The  ovaries  are  filled  with  cysts,  the  trophic  con- 
trol of  the  follicles  by  the  thyroid,  the  interstitial  ovary,  by  the 
pituitary  gland,  is  exerted  in  a  sense  hut  does  not  stimulate 
enough  or  sufficiently  and  these  Graafian  follicles  come  to  a 
certain  point  and  do  not  rupture.  A  very  thick  tunica  al- 
buginea  may  likewise  be  responsible  for  this  but  the  lack  of 
trophic  control  by  the  endocrines  is  a  frequent  factor.  Loeb 
found  that  extirpation  of  the  corpora  lutea  in  the  guinea-pig 
accelerates  the  bursting  of  ripe  Graafian  follicles  which  indi- 


AN  INTRODUCTION  TO  THE  STORY  OF  THE  ENDOCRINES      7Z 

cates  that  the  presence  of  corpora  lutea  inhibits  ovulation.  The 
corpus  luteum  of  pregnancy  inhibits  the  ripening  of  folhcles. 
Many  ovaries  contain  these  small  atresic  follicles,  they  contain 
corpus  luteum  rests,  occasionally  corpus  luteum  cysts  and  thus 
an  inhibition  of  oz'ulation  takes  place. 

Here  again  we  have  the  cases  where  as  a  result  of  treat- 
ment and  very  often  without  treatment,  or  due  to  a  change  of 
air,  or  scene  or  often  through  a  prolonged  course  of  travel, 
the  inhibition  is  removed  and  ovulation  does  take  place  with 
subsequent  pregnancy. 

While  the  corpus  luteum  is  an  important  product  of 
ovulation,  one  must  not  underestimate  the  value  of  the  ovary 
itself.  This  part  may  cause  regular  menstruation  and  yet 
ovulation  or  the  ripening  of  a  Graafian  follicle  for  the  produc- 
tion of  an  ovum  does  not  take  place. 

We  next  have  the  large  hyperovarian  condition  consist- 
ing of  those  ovaries  known  as  the  oyster  ovary.  There  is  a 
great  deal  of  interstitial  tissue  and  there  may  be  a  very  slight 
production  of  Graafian  follicles.  These  cases  not  infrequently 
show,  the  surface  studded  with  small-sized  atresic  follicles  pro- 
jecting above  the  surface.  In  these  cases  the  tunica  albuginea 
is  not  thickened,  ripe  ova  frequently  are  not  produced  or  ex- 
pelled and  yet  ovarian  secretion  is  present.  These  cases  often 
menstruate  and  menstruate  excessively.  If  in  cases  like  these 
the  ovum  is  thrown  out,  the  corpus  luteum  is  produced  and 
it  may  be  that  the  ovum  does  enter  the  uterus  but  the  stim- 
ulative effect  of  the  ovarian  secretion,  probably  aided  by 
the  pituitary,  overcomes  the  trophoblast  secretion  of  the  ovum 
when  it  imbeds  itself  and  so  the  ovum  does  not  inhibit  men- 
struation and  it  is  thrown  off  at  the  regular  menstrual  period 
or  occasionally  a  few  days  later. 

So  we  have  the  type  of  sterility  due  to  conditions  of  the 
ovaries  that  are  not  inflammatory  in  nature,  the  hypoovarian 
type  where  ovulation  does  not  take  place  because  of  ovarian 
inefficiency,  the  primary  condition  often  dependent  on  lack  of 
hypophysis  stimulation.  We  have  cases  where  the  ciliated  epi- 
thelium of  the  tubes  does  not  act,  cases  where  the  tubes  are 


74  THE    ENDOCRINES 

too  narrow,  either  in  the  sense  they  have  not  developed  or  they 
have  become  atrophic  afterward.  Then  we  have  ovaries  with 
contained  atresia  follicles,  corpus  luteum  rests  or  corpus  luteum 
cysts,  follicle  cysts  which  inhibit  ovulation.  We  must  add  that 
hyperpituitary  type  where  imbedding  of  the  ovary  does  not 
continue  and  where  repeated  probable  early  casting  off  of  the 
fecundated  ovum  takes  place.  In  connection  with  this  study 
of  sterility  it  is  of  interest  to  state  the  following  observed  in 
the  cow : 

In  the  cow  the  corpus  luteum  is  about  5/6  inch  in  diameter. 

It  remains  for  the  310  days,  that  is  280  days  plus  30  days 
postpartum.  (Metritis  and  pyometra  of  abortion,  at  pre- 
mature labor  or  at  full  term,  may  cause  the  corpus  luteum  to 
remain  permanently  in  the  ovary.)  If  there  is  no  pregnancy, 
the  corpus  luteum  shrinks  to  one-fourth  of  its  size  twenty 
days  after  the  estrum,  and  a  new  corpus  luteum  appears  in  the 
other  ovary.  If  there  is  no  pregnancy,  the  corpus  luteum  may 
form  a  corpus  luteum  cyst  which  tends  to  prevent  ovulation, 
but  often  other  corpora  lutea  form  and  develop  into  cysts. 
Small  cysts  in  the  ovary  are  inimical  to  breeding  but  not  pro- 
hibitive. They  may  cause  nymphomania  and  a  remarkable 
laxity  of  the  broad  ligament.  Larger  cysts  4  to  8  inches  in 
diameter  destroy  the  ovarian  tissue,  but  the  other  ovary  may 
be  normal.  Hypertrophied  yellow  bodies,  ovarian  corpus  lu- 
teum cysts  if  squeezed  out  are  followed  by  ripening  of  a  cor- 
pus luteum  in  the  ovary  very  quickly. 

To  repeat :  On  the  one  hand  we  may  have  primary  or 
secondary  involvement  of  the  ovaries  with  injury  to  the  follicle 
and  interstitial  apparatus  and  diminished  or  absent  menstrua- 
tion. On  the  other  hand,  we  may  have  primary  or  secondary 
involvement  of  the  ovaries  with  no  ovulation,  and  yet  men- 
struation is  not  diminished  or  it  may  be  increased. 

In  the  glandular  therapy  of  sterility  we  administer  by 
mouth  ovarin,  corpus  luteum  extract,  hypophysis  extract,  es- 
pecially posterior  lobe,  thyroid  extract,  suprarenal  extract. 
Hypodermically  we  administer  ovarian  residue,  corpus  luteum 
extract,  pituitrin,  adrenalin.   An  excellent  combination  is  pitui- 


AX  INTRODUCTION  TO  THE  STORY  OF  THE  ENDOCRINES       75 

trin  combined  with  adrenalin,  but  this  must  be  used  in  small 
doses  at  first  for  hyperpituitary  and  hyperadrenal  patients  react 
with  too  strong  doses  and  evidence  pallor,  tremor  of  the  hands 
and  occasionally  a  decided  shakiness  of  the  extremities.  This 
procedure  is  then  of  great  diagnostic  value  since  it  contraindi- 
cates  the  use  of  these  extracts. 

The  surgical  treatment  of  this  form  of  sterility  is  of  in- 
terest. I  have  had  brilliant  results  in  several  cases  associated 
with  menorrhagia  by  performing  a  wedge-shaped  excision  and 
removing  from  each  ovary  the  thickened  tunica  albuginea  and 
the  numerous  atresic  follicles,  corpus  luteum  rests  and  occa- 
sionally a  corpus  luteum  cyst,  all  of  which  elements  by  their 
presence  and  by  their  inhibitory  influence  may  prevent  the 
bursting  of  follicles  and  the  liberation  of  the  ovum.  These 
excellent  results  are  not  obtained  in  the  cystic  conditions  of  the 
ovary  or  with  thickened  tunica  albuginea  if  menstruation  is 
diminished  or  slight  in  amount.  In  all  these  cases  care  must  be 
taken  to  split  the  ovary,  remove  the  cysts  and  save  as  much  of 
the  ovarian  tissue  as  possible. 

A  very  frequent  condition  in  women  is  asthenia,  a  con- 
dition particularly  noticeable  in  the  postpartum  period,  per- 
sisting in  many  cases  for  months  and  in  many  cases  persisting 
permanently.  The  individual  is  entirely  changed,  she  never 
regains  her  former  tone,  has  a  laxity  of  the  abdominal  mus- 
cles, has  a  gastroenteroptosis ;  there  is  nephroptosis,  hysterop- 
tosis  and  a  decided  lack  of  tone  in  the  circulatory  apparatus. 
Some  cases  suggest  a  mild  form  of  myasthenia.  In  the  study 
of  the  element  of  asthenia,  especially  postpartum  form,  we 
must  take  into  consideration  the  fact  that  during  labor  the 
placental  gland  has  been  active  and  that  this  has  a  marked 
effect  in  a  stimulating  and  inhibiting  way  on  the  other  secre- 
torv'  glands  of  the  body.  Placenta  is  a  new  element  and  it  is 
in  constant  opposition  to  the  protective  glands  of  the  body. 
The  thyroid,  ovary,  adrenals  and  pituitary  are  put  to  the  test 
in  pregnancy,  and  even  if  victorious,  the  thyroid,  but  especially, 
the  adrenals  and  pituitary,  are  exhausted  in  many  instances. 


Td  THE    ENDOCRINES 

The  role  of  the  parathyroid  must  be  of  importance  in 
pregnancy.  The  principal  role  of  the  parathyroids  is  their 
control  over  calcium  metabolism.  Calcium  moderates  the 
activity  of  the  nerve  cells.  With  too  great  a  loss  of  calcium 
the  patient  is  in  an  excitable  state.  With  a  diminution  of  para- 
thyroid secretion,  tetany  may  occur  more  readily  if  the  sub- 
ject becomes  pregnant  or  is  injected  with  placental  extract  or 
if  she  nurse.  Hence  we  should  give  parathyroid  in  chorea, 
in  epilepsy,  in  eclampsia.  In  Graves'  disease  the  parathyroid 
is  often  involved.  Excessive  action  of  the  parathyroid  is  sup- 
posed to  be  responsible  for  myasthenia  gravis.  The  parathy- 
roid to  a  certain  degree  restrains  the  thyroid  and  since  they 
are  antagonistic,  we  are  advised  to  give  parathyroid  in  Graves' 
disease  but  not  in  myxedema. 

The  ovary,  too,  is  related  to  calcium  metabolism,  and  we 
have  in  osteomalacia  what  may  be  considered  as  excessive 
action.  While  it  has  been  claimed  that  osteomalacia  is  due 
to  the  withdrawal  by  the  pregnant  uterus  of  the  adrenalin 
from  the  osseous  tissue,  since  adrenalin  furthers  the  absorption 
of  calcium  by  the  osseous  system,  nevertheless  83  per  cent,  of 
the  cases  of  osteomalacia  are  cured  by  castration.  We  know 
that  castration  causes  an  increase  in  growth  and  in  the  length 
of  the  bones. 

Acromegaly  and  osteomalacia  are  opposite  conditions  as 
regards  the  ovarian  state.  While  osteomalacia  may  be  bene- 
fited by  adrenalin,  it  is  benefited  more  markedly  by  pituitrin 
and  the  pain  in  the  bones  and  general  motility  are  thereby  im- 
proved. 

The  adrenal  cortex  is  enlarged  in  pregnancy.  In  the  early 
months  of  pregnancy,  however,  there  is  a  change  of  certain 
functions  of  the  adrenals.  Changes  occur  later  in  the  adrenal 
cortex  cells  which  give  evidence  of  a  secretory  alteration. 
Chloasma  uterinum  and  pigmentation  may  here  find  their  ex- 
planation. The  placenta  may  be  responsible  for  the  adrenal 
action  in  this  particular.  The  adrenals  aid  and  protect  against 
intoxication.  The  placenta  has  in  all  probability  normally  an 
antagonistic  restraining  action  upon  the  posterior  lobe  of  the 


AN  INTRODUCTION  TO  THE  STORY  OF  THE  ENDOCRINES      77 

pituitary.  It  has  been  antagonized  by  the  other  glands  of  the 
body,  the  thyroid  and  adrenals,  for  the  protection  of  the  sys- 
tem, protecting  the  body  against  too  great  an  invasion  by  the 
chorionic  epithelium,  protecting  the  system  against  the  toxemia 
of  pregnancy. 

The  balance  of  the  endocrine  system  has  been  upset,  there 
is  often  after  labor  an  underfunction  of  the  hypophysis,  of  the 
adrenals  and  of  the  thyroid,  a  postpartum  asthenia.  Hence 
glands  may  evidence  a  tendency  to  fatigue  and  for  that  reason 
the  degree  of  asthenia  may  be  so  marked  in  a  patient  in  whom 
these  glands  are  not  normally  over  strong,  that  the  resulting 
condition  may  last  as  I  have  said  for  months  and  years. 

As  regards  pregnancy  let  us  say  that  hydatid  mole  and 
chorioepithelioma  are  local  somatic  ezndcnccs  of  placental  ag- 
gression. Let  us  say  that  eclampsia  is  the  systemic  evidence 
of  placental  aggression  and  let  us  call  puerperal  mania  and 
puerperal  psychoses  the  psychic  evidences.  Let  us  call  as- 
thenia postpartum  endocrine  exhaustion  due  to  placental  ag- 
gression. 

In  many  cases  we  may  benefit  these  patients  decidedly  by 
the  administration  of  one  or  other  of  these  glands,  with  ovarian 
extract  too  if  that  is  indicated.  Many  patients  improve  quickly 
while  in  others  the  course  of  progress  is  very  slow. 

In  the  consideration  of  asthenia  we  must  remember  that 
the  hypophysis  has  an  anterior  and  a  posterior  lobe,  the  an- 
terior lobe  being  concerned  with  physical  development  and 
physical  strength,  while  the  posterior  lobe  is  more  intimately 
concerned  with  genital  function.  Hence  in  asthenia  if  men- 
struation be  normal  the  anterior  lobe  is  the  more  important 
extract  to  administer.  The  relationship  of  the  anterior  lobe 
to  various  functions  is  more  marked  in  the  male  than  in  the 
female,  accounting  for  the  greater  strength  of  the  male.  In 
many  women  in  whom  the  anterior  lobe  plays  a  more  than 
normal  part,  we  have  the  large  body  framework  and  the  great 
strength.  If  there  be  no  coordinate  activity  of  the  posterior 
lobe,  there  is  either  a  diminished  development  of  the  genitalia 
or  the  diminished  tendency  to  feminism.     With  these  facts  in 


78  THE   ENDOCRINES 

mind  we  may  realize  the  stimulative  action  of  anterior  lobe 
extract  in  asthenia.  Blood  pressure  in  these  cases  may  be  ex- 
tremely low.  Indications  for  the  administration  of  suprarenal 
extract  and  pituitary  extract  for  long  periods  is  decided.  I 
have  a  strong  suspicion  that  the  anterior  and  posterior  lobes 
are  antagonistic  as  regards  their  action  on  the  female  genitalia. 
Hence  in  giving  anterior  lobe  extract  in  cases  of  diminished 
menstruation,  posterior  lobe  extract  and  ovarian  extract  should 
likewise  be  given. 

We  must  not  in  our  zeal  for  endocrinology  overlook  the 
essentials  of  medical  treatment.  Iron,  arsenic,  overfeeding, 
baths,  massage,  change  of  air  and  scene,  and  other  medical 
measures  are  of  the  greatest  importance,  and  the  action  of 
many  of  these  methods  is  probably  directed  to  the  stimulation 
which  is  exerted  not  only  on  the  system  in  general,  but  on 
the  blood-forming  function  and  the  secretory  function  of  the 
various  glands  to  which  we  have  just  referred. 

Thyroid  hyperfunction  of  the  extreme  type  known  as 
Graves'  disease,  thyroid  hypofunction  of  the  extreme  type 
known  as  myxedema,  are  associated  with  anomalies  of  men- 
struation. Between  the  excessive  type  known  as  Graves'  dis- 
ease on  the  one  hand  and  myxedema  on  the  other,  there  are 
innumerable  gradations  from  the  extreme  down  to  the  types 
which  are  scarcely  recognized.  And  here  again  we  may  have 
anomalies  of  menstruation. 

Whatever  we  may  find  to  be  the  ultimate  primary  causes 
of  exophthalmic  goiter  on  the  one  hand  and  myxedema  on 
the  other,  the  fact  remains  that  thyroid  diseases  are  six  to 
eight  times  more  frequent  in  the  female  than  in  the  male.  This 
again  proves  the  element  of  instability.  This  is  a  point  to 
remember,  that  of  about  three  thousand  cases  of  Based ozi/s 
disease  only  one  hundred  and  eighty-Uve  developed  before 
sixteen. 

When  we  consider  the  nervous  and  digestive  symptoms  of 
exophthalmic  goiter  and  the  mental  upset  associated  with  this 
condition,  and  the  metabolic  changes  and.  physical  and  mental 
lack  of  tone  and  energy  in  myxedema,  we  perceive  that  in 


AN  INTRODUCTION  TO  THE  STORY  OF  THE  ENDOCRINES      79 

these  extreme  types  and  in  innumerable  gradations  down  to 
the  slightest  forms,  we  may  include  thousands  and  thousands 
of  patients  suffering  from  hyperthyroidism,  or  hypothyroid- 
ism with  the  innumerable  variations  in  the  symptoms,  the  ma- 
jority of  zvhich  have  been  considered  in  times  past  as  hysterical 
or  neurasthenic. 

The  first  truth  to  be  recognized  in  the  study  of  the  En- 
docrine System  is  that  an  upset  in  any  one  gland  has  an  effect 
on  the  whole  cycle,  causing  overactivity  or  underactivity  of 
one  of  more  or  of  all  or  of  many.  This  introduces  all  the 
various  changes  belonging  to  hypersecretion  and  hyposecre- 
tion  of  the  other  glands,  particularly  the  adrenals,  hypophysis, 
thyroid  and  ovary.  The  triangle  of  thyroid,  adrenals  and 
pancreas  is  well  known.  The  adrenals  are  intimately  asso- 
ciated with  the  pancreas,  the  pancreas  is  intimately  associated 
with  digestion,  sugar  metabolism  and  the  liver  function. 
Hence  a  thyroid  affection,  either  hypersecretion  or  hyposecre- 
tion,  acts  through  the  adrenals  on  the  pancreas  itself,  and 
through  these  three  organs  there  is  a  change  in  metabolism 
and  liver  function.  Besides  thyroid  stimulates  peristalsis  and 
intestinal  secretion.  Hence  the  innumerable  digestive  annoy- 
ances associated  with  hyperthyroidism  particularly. 

Then  we  know  of  the  relationship  between  the  hypophysis 
on  the  one  hand  and  the  thyroid  on  the  other  with  the  well 
known  advantages  of  giving  hypophysis  extract  in  some  cases 
of  hyperthyroidism. 

The  pituitary  cannot  take  the  place  of  the  thyroid  in  ani- 
mals affected  with  cachexia  thyreopriva,  nor  is  pituitary  extract 
able  to  take  the  place  of  thyroid  extract  in  the  treatment  of 
goiter  and  myxedema.  There  is  no  evidence  that  these  two 
organs  act  vicariously.  The  effect  of  their  injection  is  entirely 
different,  but  they  do  have  a  certain  similarity  of  function 
in  relation  to  growth  and  development  (Schafer).  So  that 
the  variations  in  the  symptoms  occurring  in  hyperthyroidism 
or  in  hypothyroidism  associated  more  or  less  directly  with 
ovarian  function,  produce  a  mixture  and  a  confusion  of  symp- 


80  THE   ENDOCRINES 

toms  which  in  many  cases  take  weeks  or  months  of  observa- 
tion to  decipher  and  to  definitely  correct. 

At  the  chmacteric  period  we  are  confronted  with  a  sup- 
posedly normal  waning  of  the  ovarian  function  associated  with 
which  there  should  be  a  very  gradual  progressive  diminution 
of  thyroid  activity.  The  relationship  between  the  ovaries  and 
the  thyroid  and  the  other  glands  of  internal  secretion,  at  this 
period,  is  extremely  unstable,  which  accounts  for  the  numerous 
annoyances  from  which  women  suffer.  I  refer  not  only  to  the 
flashes  or  flushes  supposed  to  be  typical  of  the  menopause,  but 
to  the  psychic  and  nervous  manifestations  so  frequently  ob- 
served at  this  period. 

We  distinguish  during  the  climacterium  and  the  meno- 
pause stage  three  alterations  in  the  activity  of  the  thyroid 
gland.  One  a  more  or  less  continuous  hyperactivity  of  the 
thyroid,  the  second  a  more  or  less  underactivity  of  the  thy- 
roid, the  third  such  a  marked  instability  of  the  gland  that  at 
times  hyperthyroidism  is  evident  and  at  other  times  hypothy- 
roidism is  evident.  Therefore  in  the  first  type  we  have  the 
overexcitable  type,  in  the  second  we  have  the  depressed  type, 
in  the  third  we  have  the  type  alternating  between  the  one  and 
the  other,  ofttimes  suggesting  the  manic-depressive  type  of 
insanity.  Here  again  we  have  an  involvement  of  the  other 
glands.  We  may  have  an  overactivity  of  the  anterior  lobe  of 
the  hypophysis  inasmuch  as  the  inhibition  by  the  ovary  is  re- 
moved. Hence  the  trichosis  and  the  other  evidence  of  anterior 
lobe  overactivity.  We  may  have  an  alteration  often  enough 
in  the  posterior  lobe,  a  diminution  of  its  activity  leading  to 
obesity  and  a  high  sugar  tolerance. 

If  we  have  an  overactivity  in  the  anterior  or  posterior 
lobe,  that  accounts  for  the  increased  tendency  to  sugar  at 
these  stages,  lasting  for  various  periods  or  even  continuous 
and  permanent.  Then  come  the  variations  in  the  adrenal  func- 
tion giving  us  the  hypoadrenal  type,  the  low  blood  pressure 
type,  and  the  hyperadrenal  type,  the  high  blood  pressure  type 
so  frequently  encountered  at  this  period  without  evidence  of 
kidney  Involvement.     With  low  pressure  hypopituitarism  Is 


AN  INTRODUCTION  TO  THE  STORY  OF  THE  ENDOCRINES       81 

to  be  considered.  With  high  pressure  excessive  action  of  the 
posterior  pituitary  lobe  is  suggested. 

With  hypopituitarism  we  have  the  subnormal  tempera- 
ture, slow  pulse  and  low  blood  pressure,  with  drowsiness  and 
dullness. 

The  various  alterations  in  these  three  or  four  glands  pro- 
duce innumerable  combinations  of  symptoms  and  explain  the 
variability  of  symptoms  even  in  the  same  patient  on  various 
days,  weeks  and  months. 

Since  thyroidectomy  results  in  growth  of  the  pituitary 
gland,  especially  the  anterior  part,  it  is  probable  that  this  may 
occur  too  in  hypothyroidism  and  the  myxedematous  forms. 

The  pituitary  and  the  suprarenal  are  closely  related  and 
we  know  that  an  injection  of  adrenalin  markedly  increases  the 
efficacy  of  pituitrin  and  vice  versa. 

The  posterior  lobe  extract  stimulates  the  flow  of  cerebro- 
spinal fluid.  The  secretion  of  the  posterior  lobe  is  excited  by 
duodenal  extract,  if  injected  into  the  circulation,  which  ca'uses 
its  hormones  to  be  thrown  out  in  increased  degree  into  the 
cerebrospinal  fluid. 

The  pituitary  and  the  suprarenals  are  associated  func- 
tionally with  the  pancreas  and  the  liver.  The  thyroid  is  like- 
wise concerned  with  carbohydrate  metabolism  and  hypothy- 
roidism is  associated  with  increased  sugar  tolerance. 

Since  hypothyroidism  is  often  associated  with  increased 
activity  of  the  posterior  pituitary  lobe,  the  high  sugar  tolerance 
of  the  former  may  be  modified.  This  combination  is  respon- 
sible for  high  blood  pressure.  If  both  thyroid  and  posterior 
lobe  are  deficient  there  must  be  a  markedly  increased  sugar 
tolerance.  If  both  thyroid  secretion  and  posterior  lobe  are 
increased  there  is  an  increased  tendency  to  the  opposite  con- 
dition. Hence  an  altered  relation  in  the  secretions  of  the  thy- 
roid, pituitary  and  adrenals  may,  owing  to  their  relation  to 
the  pancreas  and  the  liver,  markedly  influence  sugar  tolerance 
and  thus  bear  a  close  connection  to  diabetes  mellitus  or  dia- 
betes insipidus  and  to  blood  pressure.  Adiposity  due  entirelv 
to  posterior  lobe  insufficiency,  hence,  may  not  alwavs  evidence 


82  THE    ENDOCRINES 

polyuria  and  may  even  have  glycosuria.  Earnest  claims  are 
made,  however,  that  hypopituitarism  is  the  cause  of  polyuria 
and  diabetes  insipidus  (true).  In  this  connection  it  may  be 
mentioned  that  in  acromegaly  in  the  active  stage  of  oversecre- 
tion  30  to  50  per  cent,  evidence  glycosuria.  If  anterior  lobe 
growth  or  hyperactivity  interferes  with  activity  of  the  posterior 
lobe  or  if  hypersecretion  of  anterior  lobe  is  followed  by  a  state 
of  exhaustion  of  the  gland  and  the  posterior  lobe  is  also  dimin- 
ished in  function,  then  high  sugar  tolerance  eventually  follows 
in  acromegaly. 

With  the  hypothyroid  type  we  have  the  slow  pulse,  with 
the  hyperthyroid  type  we  have  the  rapid  pulse  and  various 
types  of  tachycardia. 

With  the  adrenal  involvement  we  have  the  normal  blood 
pressure,  the  low  blood  pressure  or  the  high  blood  pressure. 
We  may  have  the  types  that  are  extremely  adipose  evidencing 
here  both  the  thyroid  type  and  the  hypophysis  type. 

With  the  hypothyroidism  we  may  have  a  lack  of  proper 
stimulation  to  the  metabolic  processes,  giving  us  the  thin  pa- 
tient, whereas  we  ordinarily  think  that  a  diminished  metabolism 
gives  us  the  stout  patient. 

In  the  hyperthyroid  type  we  have  the  excessive  metabolism, 
giving  us  in  many  cases  a  thin  patient  unless  there  is  associated 
with  this  a  hypoactivity  of  the  posterior  lobe  which  then  again 
introduces  the  phase  of  obesity  and  the  high  sugar  tolerance. 

So  we  have  to  rely  for  our  diagnosis  of  these  cases  on 
their  psychic  manifestations,  their  nervous  irritability,  the 
pulse-rate,  the  blood  pressure,  presence  or  absence  of  sugar 
in  the  urine  and  blood,  high  or  low  sugar  tolerance,  trichosis, 
obesity,  tremor,  etc. 

The  administration  of  the  various  gland  extracts  gives  us 
in  many  cases  the  key  to  the  situation.  The  hyperthyroid  type 
is  readily  recognized  by  the  effect  of  thyroid.  Hyperpituitar- 
ism (post.)  may  be  disclosed  by  a  hypodermic  of  pituitrln. 
The  low-pressure  type  is  readily  recognized  by  the  effect  of 
adrenalin,  suprarenal  and  pituitary  extract,  and  in  many  cases 
a  combination  of  the  three  is  necessary.     Ovarian  extract  and 


AN  INTRODUCTION  TO  THE  STORY  OF  THE  ENDOCRINES      83 

ovarian  residue  for  the  flushes  are  in  many  cases  specific  in 
effect.  Here  again  we  must  not  fail  to  consider  the  value  of 
other  gland  extracts  or  other  methods  as  diet,  baths,  massage, 
bromides,  hypnotics  and  the  various  sedatives. 

Just  as  severe  monthly  premenstrual  symptoms  speak  for 
a  poorly  balanced  endocrine  system,  so  a  severe  menopause 
experience  speaks  for  the  same  and  a  placid  climacterium  de^ 
notes  a  well  balanced  inter glandidar  relation. 

Like  changes  of  lesser  degree  between  the  glands  may 
occur  in  women  at  any  period  and  often  in  the  years  preceding 
the  climacterium.  Unfortunately,  in  many  of  these  cases  men- 
struation is  not  affected.  If  it  were,  our  attention  then  would 
be  attracted  more  readily.  A  slow  pulse  in  a  patient  always 
calls  my  attention  to  an  underaction  on  the  part  of  the  thyroid 
or  to  an  underaction  on  the  part  of  the  hypophysis.  A  rapid 
pulse  not  even  faster  than  90  or  100  always  calls  my  attention 
to  a  condition  of  hyperthyroidism  or  hyperadrenalism. 

The  excessive  irritability  of  some  patients,  their  nervous- 
ness, their  instability,  should  call  our  attention  to  anomalies 
of  the  secretory  apparatus  in  the  thyroid,  adrenals  or  hypo- 
physis. In  overactivity  of  the  hypophysis  we  have  the  tem- 
peramental changes,  such  as  lack  of  concentration,  feeling  of 
distress,  indecision  and  irritability.  The  opposite  is  seen  in 
dullness,  indecision,  lack  of  energy,  tendency  to  melancholia, 
poor  memory  and  the  blues,  pointing  to  an  underactivity  on 
the  part  of  the  hypophysis  gland. 

In  early  underactivity  of  the  pituitary  we  have  hypo- 
trichosis, little  axillary  and  pubic  hair,  the  sexual  apparatus 
develops  poorly  or  becomes  atrophic,  the  skin  is  smooth  or 
rough  but  dry,  there  are  often  polyuria  and  a  high  sugar  tol- 
erance. There  may  be  subnormal  temperature  and  slow  pulse. 
There  is  also  a  frequent  combination  of  psychoses,  nervous 
conditions ;  and  even  epilepsy  has  been  noted.  In  many  cases  of 
goiter  the  hypophysis  is  found  affected.  Whatever  chemical 
factors  cause  the  hypophysis  to  become  hyperplastic  the  same 
factors  act  upon  the  thyroid.  Almost  all  the  hypophysis  cases 
are  eventually  deficient  even  if  the  condition  is  hyperplastic 


84  THE   ENDOCRINES 

at  first.  So  practically  all  the  typical  hypophysis  cases  of 
Gushing  showed  a  thyroid  deficiency. 

Hence  I  have  found  it  of  extreme  value  to  administer 
ovarian  residue  and  ovarian  extract  in  large  doses  by  mouth 
and  by  needle  in  cases  of  hyperthyroidism.  Pituitary  extract 
and  placenta  are  often  of  great  aid.  Corpus  luteum  may 
diminish  blood  pressure  if  it  inhibits  the  posterior  pituitary.  I 
am  astonished  that  in  this  condition  the  value  of  these  extracts 
is  not  more  generally  recognized.  The  value  of  thyroid  in 
the  cases  of  myxedema  and  in  the  ofttimes  unrecognized  cases 
of  underactivity  of  the  thyroid  is  so  marked  that  no  one  can 
mistake  the  value  of  this  therapy. 

Thyroid  extract  is  of  great  value  too  as  a  diagnostic  aid, 
for  not  infrequently  in  certain  puzzling  cases  we  get  an  ag- 
gravation of  the  symptoms,  an  increased  irritability  and  an 
increasedly  rapid  heart,  and  we  know  that  we' are  dealing  with 
a  sensitive  thyroid  and  not  a  hyposecretion. 

Undoubtedly  the  greatest  difficulty  in  the  proper  inter- 
pretation of  interglandular  upset  depends  upon  the  fact  that 
so  many  of  them  are  of  minor  degree,  of  a  degree  less  than 
is  typical  of  the  well  exemplified  cases. 

If  we  have  exophthalmic  goiter  on  the  one  hand  and 
myxedema  on  the  other;  gigantism  or  acromegaly  on  the  one 
side,  certain  types  of  dwarfs  or  dystrophia  adiposogenitalis  on 
the  other  side;  if  we  have  tetany  and  paralysis  agitans  on  the 
one  hand,  and  myasthenia  gravis  on  the  other ;  if  we  have  ex- 
cessive sexual  and  physical  development  due  to  tumors  of  the 
pineal,  the  hypophysis  and  the  adrenals  and  testis  on  the  one 
hand  and  cases  of  undeveloped  genitalia  and  infantile  uterus 
on  the  other;  if  we  have  acromegaly  on  the  one  hand  and 
osteomalacia  on  the  other;  if  we  have  excessive  function  and 
menstruation  through  oyster  ovaries  on  the  one  hand  and 
diminished  function  and  relative  amenorrhea  through  ovarian 
hypoplasia  and  degeneratio-adiposo-genitalis  on  the  other;  if 
we  have  the  extreme  adrenal  disease  known  as  Addison's 
disease;  zvhy  may  zue  not  expect  minor -degrees  of  involvement 
in  the  glands  or  pluriglands  responsible  for  these  major  cases. 


AN  INTRODUCTION  TO  THE  STORY  OF  THE  ENDOCRINES      85 

the  resulting  syinpfonis  Jicrc  often  lacking  the  typical  ear- 
marks which  define  the  standard  types  of  zvhich  zee  Jiaz'c  made 
mention  F 

If  instability  of  gland  function  is  transmitted  we  have  a 
new  basis  for  predicating  the  various  types  of  abnormality 
which  may  be  inherited.  Inherited  instabihty  of  the  thyroid 
may  lead  in  the  progeny  to  either  myxedema  or  to  exophthal- 
mic goiter  or  to  variations  between  these  extremes.  Inherited 
instability  of  the  hypophysis  may  lead  to  small  stature  or  to 
large  growth,  or  to  simply  the  psychic  manifestations  of  dys- 
pituitarism.  So  that  one  member  of  a  family  may  inherit  from 
his  parents  or  grandparents  these  somatic  changes  due  to  gland 
anomalies  or  one  may  inherit  the  nervous  tendencies  or  the 
instability  of  the  nervous  system  or  psychoses  resulting  from 
anomalies  of  the  internal  gland  secretions. 

A  transmitted  instability  of  internal  gland  secretion  may 
not  manifest  itself  until  some  exciting  cause  appears,  and  if 
no  exciting  causes  eventuate  the  condition  may  not  be  recog- 
nized as  an  instability.  Certain  individuals  are  more  sus- 
ceptible to  involvements  produced  by  any  of  the  inflammatory 
or  infectious  diseases.  Status  thymicus  may  give  no  warning 
until  anesthesia  or  drowning  bring  the  concealed  condition  to 
the  surface.  Pregnancy  and  labor  may  be  the  first  factors  to 
bring  out  the  lack  of  resistance  of  asthenia  universalis. 

We  must  distinguish  betzveen  the  somatic  and  the  mental 
or  psychic  side  of  pathological  states  due  to  the  endocrine  re- 
lation. I  have  seen  in  so  many  of  my  patients  attacks  of  men- 
tal depression  and  blues,  so  many  cases  of  excitement  and 
states  of  exaltation  of  minor  degree,  so  many  cases  where  the 
states  vary  from  slight  exaltation  to  slight  depression  without 
apparent  cause,  cases  after  labor  with  depression  of  a  mild 
melancholic  type,  that  long  ago  I  came  to  the  conclusion  that 
we  must  grant  variations  in  intensity  in  mental  diseases. 

If  we  have  the  forms  known  as  manic-depressive  insan- 
ity, dementia  precox,  melancholia,  etc.,  why  may  we  not  have 
minor  types  of  the  same  conditions  confronting  us  in  our  gyne- 
cological and  obstetric  work?     We  know  the  excitability  asso- 


86  THE   ENDOCRINES 

dated  with  the  various  grades  of  hyperthyroidism,  we  know 
the  mental  apathy  associated  with  the  various  degrees  of 
myxedema ;  we  know  the  mental  peculiarities  and  the  changes 
in  character  in  patients  with  hypophysis  alterations.  All  these 
variations  noted  from  time  to  titne  in  my  experience  have 
convinced  me  that  mental  diseases  of  extreme  type  may  have 
the  same  relaton  to  the  milder  forms  and  to  the  so-called  neu- 
roses and  psychoses^  and  to  the  so-called  neurasthenia  and  hys- 
teria, that  the  major  forms  of  exophthalmic  goiter  and 
myxedema,  gigantism  and  dzvariism,  etc.,  bear  to  minor  varia- 
tions noted  every  day  in  our  experience. 

We  note  in  epidemics  varying  degrees  of  virulence  in 
successive  ravages.  We  have  all  degrees  of  eclampsia  and 
toxemia  of  pregnancy,  those  who  die  in  spite  of  all  treatment 
and  the  forms  which  recover  practically  without  treatment. 
We  have  variations  in  intellectual  ability  from  the  brightest 
to  the  average  down  to  the  mental  deficients  and  the  mental 
defectives.  The  recognition  of  the  moron  of  the  various 
grades  is  in  itself  a  fascinating  study. 

Action  of  the  endocrine  glands  of  an  unusual  nature  may 
manifest  itself  entirely  in  body  and  physical  changes.  In  an- 
other class  there  may  be  body  changes  and  psychic  or  mental 
alterations  combined.  In  a  large  class,  however,  the  altera- 
tions are  psychic,  the  physical  changes  being  of  such  a  minute 
degree  that  they  give  no  clue  to  the  involvement  of  the  glands. 
Here  in  all  probability  a  marked  pluriglandular  upset  is  at 
fault.  It  is  the  absence  of  physical  changes  in  this  class  of 
mental  diseases  that  has  probably  made  it  so  difficult  for  phy- 
sicians and  the  leading  neurologists  to  eventually  come  to 
conclusion  that  the  ductless  glands  are  responsible  for  these 
conditions.  I  had  the  pleasure  of  seeing  recently  a  case  of 
muscular  dystrophy  in  a  boy  of  fifteen.  A  first  glance  was 
sufficient  to  show  me  the  acromegalic  condition.  The  head 
was  huge,  the  forehead  large,  the  chin  prominent,  out  of  all 
proportion  to  the  body  size  and  age  of  the  boy. 

Since  in  other  cases  of  this  disease  the  somatic  changes 
may  be  diminished  or  absent,  we  may  fail  for  that  reason  to 


AN  INTRODUCTION  TO  THE  STORY  OF  THE  ENDOCRINES      87 

consider  the  endocrine  glands  as  responsible.  Why  in  one 
family  or  in  one  individual  the  body  is  changed,  in  another 
the  mind  and  psyche,  in  another  both,  is  hard  to  tell.  That 
is  a  problem  for  the  future.  Even  in  other  diseases  the  same 
problem  holds.  Syphilis  may  affect  the  bones,  the  skin,  the 
testes  or  the  nervous  system.  It  is  an  old  observation  that  if 
syphilis  in  the  tertiary  stage  affects  the  bones  or  the  testes  or 
skin,  for  instance,  the  nervous  system  is  rarely  involved.  On 
the  other  hand,  paresis  or  locomotor  ataxia  occur  in  individuals 
in  whom  there  are  no  other  somatic  evidences  and  in  whom  the 
primary  lesion  was  not  followed  by  marked  skin  lesions.  There 
must  be  in  some  individuals  a  marked  protective  influence  over 
the  cerebrospinal  structures  and  it  is  perfectly  possible  that 
among  other  glands  hypophysis  may  be  one  of  these  protective 
glands. 

I  may  say  that  we  must  come  to  the  conclusion  ev^entually 
that  all  the  physical  and  mental  states  depending  upon  en- 
docrine pathology  will  be  found  to  have  innumerable  variations 
from  the  forms  known  as  types,  to  the  slightest  degrees  of 
variations,  including  those  forms  considered  as  neurasthenia 
and  hysteria,  in  the  vast  majority  of  cases  erroneously  so.  It 
is  these  observations  repeated  time  and  again  in  my  experience 
which  have  made  me  so  hostile  to  the  diagnosis  of  reflex  in 
gynecology.  Those  innumerable  states  of  body  and  mental 
function  formerly  considered  to  be  caused  through  reflex  chan- 
nels by  cervical  erosions,  lacerations  of  the  cervix,  deviations 
in  the  position  of  the  uterus,  prolapse  of  the  ovaries,  etc.,  all 
these  have  for  years  been  treated  by  me  on  the  basis  of  en- 
docrine pathology  and  justly  so  and  most  successfully.  Most 
of  us  recall  the  furor  of  operation  for  movable  kidney  for 
the  purpose  of  curing  by  this  step  innumerable  physical  and 
psychic  symptoms.  Today  this  procedure  for  this  purpose  is 
practically  a  memory. 

In  bringing  out  the  latest  weakness  due  to  hereditary 
transmission  or  congenital  weakness,  the  accidents  of  life  also 
come  into  play  in  their  effects  upon  the  internal  glands.  Every 
infection  must  play  a  part,  the  diseases  of  childhood,  typhoid 


88  THE    ENDOCRINES 

fever,  pneumonia,  tonsilitis,  influenza,  pelvic  infections  play 
their  part  in  exerting  deleterious  influence  on  the  protective 
glands  of  the  body,  among  which  the  glands  of  internal  secre- 
tion are  the  most  important.  Mental  states  must  be  likewise 
taken  into  consideration.  We  know  the  action  of  fear  and 
anger  on  the  thyroid,  adrenals  and  the  vegetative  nervous  sys- 
tem. Long-continued  grief,  disappointment,  abnormal  sexual 
practices,  unhappiness,  excessive  mental  exertion,  shock  have 
a  direct  or  indirect  influence  on  the  internal  secretory  glands. 
Onanism,  coitus  interruptus,  sexual  longings,  etc.,  must  not 
be  given  a  minor  place  in  this  etiology. 

Who  knows  but  that  circulatory  disturbances  or  the  action 
of  as  yet  uncharted  cerebral  areas  act  upon  the  glands  of  in- 
ternal secretion  and  are  acted  upon  by  them  and  the  hormones, 
of  which  there  are  probably  many  more  in  every  gland  than 
we  now  realize.  It  is  in  the  hope  that  the  severer  forms  of 
endocrine  upset  may  yield  to  new  methods  that  I  make  the 
observations  which  now  follow. 

Cerebral  activity  as  such  is  not  only  influenced  by  the 
secretory  glands  but  probably  exerts  an  influence  on  them. 
Tumors,  even  if  not  connected  with  the  hypophysis,  and  vary- 
ing degrees  of  hydrocephalus,  influence  the  secretory  activity 
of  the  hypophysis  gland  .  The  posterior  lobe  is  connected  with 
the  cerebrospinal  fluid.  It  seems  inconceivable  that  this  gland 
should  have  been  placed  in  this  position,  its  relation  to  the 
cerebral  structures  so  close,  zvithoiit  its  having  a  marked  nu- 
tritional and  protective  value  on  these  structures.  Hence  we 
shall  understand  some  day  more  than  today,  the  relation  of 
secretory  anomalies  of  this  gland  to  cerebrospinal  conditions, 
pressures  and  the  psychic  states. 

It  is  possible  that  the  cerebral  cortex  or  that  the  nervous 
system  is  attacked  in  those  individuals  in  whom  there  is  a  lack 
of  protective  power  on  the  part  of  the  pars  nervosa  for- instance 
over  the  cerebrospinal  structures.  Who  knows  but  that  the  hy- 
pophysis secretion  may  have  an  important  action  in  this  respect. 
A  lack  of  it  may  predispose  to  involvement  of  the  cerebrospinal 
organs.    We  have  in  chorea  a  cortical  condition  which  is  often 


AN  INTRODUCTION  TO  THE  STORY  OF  THE  ENDOCRINES       89 

produced  by  what  is  known  as  a  rheumatic  infection,  not  in- 
frequently associated  subsequently  with  endocarditis.  We 
may  take  it  for  granted  that  this  rheumatic  infection  affects 
one  or  more  of  the  ductless  glands,  parathyroid  or  hypophysis 
for  instance,  producing  the  symptoms  of  chorea  associated 
with  which,  of  course,  may  be  an  involvement  of  the  circula- 
tory structures  by  the  infection  itself  only  if  the  patient  have 
an  endocarditis. 

Let  us  call  to  mind  the  work  of  Goodman  in  treating 
cases  of  chorea.  Here  a  certain  amount  of  blood  is  taken 
from  the  child,  the  blood  is  centrifuged  and  this  serum  is  in- 
jected into  the  spinal  canal  after  the  same  amount  has  been 
removed  by  spinal  puncture.  In  one-half  of  these  cases  the 
patients  lost  their  chorea  in  a  few  days,  of  the  lemainder  more 
than  half  lost  it  after  a  second  or  third  injection. 

Goodman  finds  that  only  a  small  percentage  of  children 
with  chorea  have  endocarditis.  He  estimates  it  in  his  ex- 
perience to  be  7  to  10  per  cent.  Others  estimate  it  as  high  as 
20  to  25  per  cent.,  this  possibly  holding  for  the  acute  cases  or 
the  severe  cases  which  come  into  hospital  service. 

Personally,  I  have  considered  the  connection  between  the 
infection  (rheumatic  or  otherwise)  and  chorea  perhaps  to 
exist  through  the  medium  of  the  endocrine  glands.  It  is  pos- 
sible that  in  some  cases  an  infectious  agent  involves  some  of 
the  glands,  for  instance  the  hypophysis  or  more  particularly 
the  parathyroids.  Parathyroid  has  been  used  in  chorea,  tetany, 
epilepsy  and  eclampsia.  In  Goodman's  experience  if  a  serum  de- 
rived from  the  blood  of  one  choreic  patient  is  injected  into  the 
spinal  canal  of  another  patient,  no  efifect  is  observed.  A  cure 
and  benefit  are  obtained  only  if  the  autoserum  is  used.  This 
speaks  against  an  infection  as  the  total  factor  in  chorea,  even 
in  these  so-called  rheumatic  forms.  If  the  parathyroid  is  one 
of  the  glands  involved  in  chorea  and  if  other  glands  are  also 
concerned  in  the  condition  we  might  then  readily  understand 
why  the  autoserum  only  of  the  patient  acts  when  injected  into 
the  spinal  canal.  In  other  words,  with  endocrine  pathology 
only  the  serum  of  the  patient  himself,  whatever  the  nature  of 


90  THE    ENDOCRINES 

the  upset  may  be,  should  act  as  an  antibody  when  injected  into 
the  cerebrospinal  canal. 

According  to  Gley  the  cells  of  the  choroid  plexus  are 
granular  cells,  the  activity  of  which  regulates  the  composition 
of  the  cerebrospinal  fluid  contained  in  the  cerebral  ventricles 
and  in  the  central  canal  of  the  spinal  cord.  The  cerebrospinal 
fluid  thus  formed  returns  to  the  blood  by  the  perivascular 
sheaths,  the  lymphatic  paths  and  the  blood-vessels  of  the  dura 
mater.  Thus  it  might  be  said  that  "the  choroid  plexuses  are 
glands  of  external  secretion  but  having  an  internal  destiny." 
This  calls  to  mind  the  possibility  of  endocrine  hormonic 
changes  which  may  affect  the  cells  of  the  choroid  plexus  or  the 
return  paths  and  may  thus  account  for  the  entrance  of  fluid 
and  toxic  substances  and  for  their  inability  to  be  excreted. 

On  reading  Dercum's  observations  concerning  dementia 
precox  the  thought  occurred  to  me  that  possibly  the  same 
method  of  treatment  might  be  advisable  here,  namely  to  with- 
draw blood  from  the  system  and  inject  a  serum  into  the  cere- 
brospinal canal  after  removal  of  a  certain  amount  of  the  fluid. 
Dercum  states  that  while  no  treatment  of  this  sort  to  his 
knowledge  has  been  attempted,  he  has  noticed  that  the  with- 
drawal of  cerebrospinal  fluid  had  improved  some  of  these 
cases  notably.  In  all  mental  diseases  in  which  the  cortex  is 
involved,  or  cortical  centers,  it  may  be  found  that  this  line  of 
treatment  might  be  of  value  on  the  theory  that,  while  in  the 
blood  toxins  and  antitoxins  are  produced,  the  toxins  only  have 
an  effect  on  the  cerebrospinal  structures,  the  antitoxins  not 
finding  entrance  thereto  or  not  in  sufficient  power.  On  the  other 
hand,  it  may  be  that  the  antitoxins  are  insufficient  or  not 
formed  at  all  within  the  cerebrospinal  canal.  Spinal  puncture 
removes  these  toxic  products  and  if  antitoxins  are  produced 
in  the  general  system  as  one  would  expect,  if  the  ductless 
glands  are  concerned  with  the  production  of  antitoxins,  then 
injection  of  the  same  into  the  cerebrospinal  canal  would  pro- 
duce a  beneficial  result.  It  may  be  that  in  normal  individuals 
toxins  and  antitoxins  enter  and  leave  the  cerebrospinal  canal 
and  that  when  this  mechanism  of  exchange  is  affected,  whereby 


AN  INTRODUCTION  TO  THE  STORY  OF  THE  ENDOCRINES      91 

toxins  enter  and  cannot  be  excreted,  and  when  the  antitoxins 
in  the  blood  cannot  enter  or  are  introduced  in  insufficient 
quantity,  that  we  then  have  the  resulting  mental  and  psychic 
alterations  which  may  perhaps  be  cured  by  spinal  puncture 
and  its  replacement  by  the  antibodies  in  the  autoserum. 

Every  man  interested  in  any  particular  specialty  may  at 
any  time  fix  his  attention  on  any  one  gland  of  the  body.  To 
begin  the  study  of  any  one  gland,  one  must  study  the  relation 
of  the  other  glands  to  it,  in  the  trophic  sense  or  in  the  in- 
hibitory sense.  We  must  study  the  value  of  any  one  gland 
diagrammatically  so  to  speal:.  We  must  put  above  it,  in  a 
stream  of  thought  or  on  paper,  those  glands  which  inhibit  it ; 
we  must  put  under  it  in  a  stream  of  thought  or  on  paper  those 
glands  which  support  it. 

When  that  one  gland  in  which  we  are  interested  shows 
anomalies,  we  must  look  and  see  what  glands  are  failing  in 
their  support  and  which  glands  are  overacting  or  underacting 
in  a  secretory  way.  This  leads  us  into  a  maze  of  combinations 
which  require  much  study  in  many  individual  cases  to  unravel 
and  to  help.  It  is  needless  to  say  that  many  of  these  gland 
anomalies  can  be  helped  only  by  surgical  means.  Graves' 
disease  is  the  finest  example.  The  beneficial  effects  of  opera- 
tion on  exophthalmic  goiter  are  well  known.  Gushing  has 
shown  us  the  value  of  operations  on  the  hypophysis  gland, 
where  pressure  symptoms  are  the  important  thing.  Hyper- 
ovarianism  with  persistent  menorrhagia  is  another.  I  have 
cured  several  cases  of  persistent  menorrhagia  and  metrorrhagia 
by  resection  of  part  of  each  ovary.  Some  cases  of  sterility 
come  into  the  surgical  class  by  resection  of  half  of  each  ovary 
in  those  cases  of  sterility  when  menstruation  is  normal  or 
excessive  and  yet  ovulation  seems  not  to  take  place.  Osteoma- 
lacia is  another  condition  corrected  in  the  majority  of  instances 
by  surgical  means. 

I  have  attempted  to  review  the  elements  of  the  internal 
secretory  glands  in  gynecology  from  the  broader  standpoint  of 
the  physician.  Our  concern  is  to  understand  the  underactivity 
of  certain  glands  and  to  support  them  by  administering  to  the 


92  THE    ENDOCRINES 

patient  substances  which  are  insufficient,  and  by  attempting 
to  inhibit  those  glands  whose  functions  for  the  moment  are 
hyper.  Do  not  think  because  I  have  praised  so  much  the  value 
of  ovarian  extract,  ovarian  residue  and  corpus  luteum  that  I 
think  the  ovarian  function  dominates  the  whole  cycle.  Prac- 
tically speaking,  the  thyroid  and  ovarian  and  hypophysis  ex- 
tracts  have  proved  their  very  great  value  in  gyneocology.  It 
is  simply  because  faulty  ovarian  function  shows  us  that  there 
is  an  upset  in  the  cycle  that  we  lay  so  much  stress  on  the  ovaries 
and  the  restoration  of  proper  secretory  activity,  hoping  thereby 
to  aid  in  restoring  a  normal  balance  when  pluriglandular  com- 
plications are  in  evidence.  Eventually  we  shall  find  and  dif- 
ferentiate the  numerous  hormones  in  every  gland  in  the  en- 
docrine system.  We  shall  find  that  many  of  them  have  a 
somewhat  similar  relation  to  physical  and  mental  growth,  but 
we  shall  eventually  discover  the  selective  action  of  the  various 
hormones. 

I  have  no  doubt  that  just  as  in  poliom3^elitis,  chorea  and 
syphilis  certain  areas  are  affected  by  selection  by  bacteria  and 
the  toxic  products  of  the  infection,  so  the  various  hormones 
both  in  health  and  disease  manifest  the  selective  influence  of 
the  endocrine  glands.  That  innumerable  variations  must  re- 
sult dependent  on  interglandular  relations  and  the  congenital 
physical  and  mental  characteristics  of  the  individual  is  a  ra- 
tional conclusion. 

Let  me  conclude  with  the  opening  paragraph: 
If  we  can  fathom  and  understand  what  the  ductless  glands 
have  done  to  an  individual  up  to  the  stage  of  puberty,  we 
may  appreciate  why  the  individual  develops  as  he  does.  If 
we  can  reason  out  what  those  ductless  glands  have  done  to  that 
individual  from  puberty  on,  we  may  understand  why  that  in- 
dividual is  what  he  is  and  why  so  many  changes  have  occurred 
in  him.  If  we  can  eventually  fathom  what  hereditary  and 
accidental  and  intercurrent  factors  are  responsible  for  these 
gland  changes  and  for  the  consequent  somatic,  mental  and 
psychic  factors,  then  medicine  zvill  have  accomplished  a  glori- 
ous work. 


CHAPTER    IV 

INTERNAL  SECRETIONS 
Pineal  Gland 

Total  destruction  of  the  pineal  gland  by  malignant  tumor 
results  in  profound  cachexia  with  trophic  derangement.  Pineal 
tumor  results  in  obesity  but  not  genital  atrophy.  Pineal  obes- 
ity is  probably  due  to  hyperfunction,  but  this  is  not  certain, 
because  obesity  is  observed  in  pineal  disease  where  there  is 
certainly  a  reduction  of  secretion.  Pineal  tumor,  generally 
teratoma  in  boys  of  under  seven  years,  produces  abnormal 
growth  in  height,  abnormal  growth  of  hair,  premature  de- 
velopment of  the  genitalia  and  of  sexual  instinct,  and  mental 
precocity.  In  these  cases  the  changes  were  associated  with  a 
diminution  of  the  pineal  tissue.  During  the  period  of  the 
complete  development  of  the  pineal  gland — that  is,  until  the 
seventh  year — this  organ  normally  exerts  an  inhibitory  influ- 
ence upon  the  development  of  the  sexual  glands,  and  probably 
has  a  secondary  effect  on  mental  development.  Destruction 
of  the  pineal  gland  at  this  stage  leads  to  physical  precocity. 
There  is  an  antagonism  between  pineal  gland  and  hypophysis, 
for  pituitary  insufficiency  causes  hypogenitalism.  It  appears 
that  in  adult  animals  the  pineal  gland  is  of  lesser  consequence. 
The  pineal  gland  shows  its  chief  functional  activity  in 
childhood ;  a  significant  involution  of  the  structure  occurs  at 
puberty.  Pineal  enlargement,  whether  associated  with  hyper- 
plasia or  hypoplasia,  may  produce  a  tendency  toward  adiposity. 
Certain  types  of  pineal  tumor  are  characterized  by  extra- 
ordinary precocious  puberty.  According  to  Frankl-Hochwart, 
"when  in  a  young  individual  (boy)  there  is  increase  in  stature 
and  unaccustomed  growth  of  hair,  obesity,  drowsiness,  a  pre- 
mature genital  and  sexual  development,  wath  evidence  of 
precocity  of  adolescence,  pineal  tumor  must  be  thought  of." 

Thymus 

When  the  thymus  is  removed  in  dogs  they  die  in  a  year. 
After  a  fourteen-day  period  of  latency,  they  become  for  the 

93 


94  THE    ENDOCRINES 

next  two  or  three  months  of  a  spong-y  appearance,  are  easily 
tired,  have  a  pecuHar  walk,  show  apathy,  a  diminished  intelli- 
gence, and  a  most  unusual  hunger  (stadium  adipositatis). 
This  passes  over  into  the  terminal  cachectic  stage,  which  lasts 
three  to  six  months.  In  spite  of  their  hunger  they  are  more 
unsteady,  show  attacks  of  muscular  tremor,  lose  their  hair,  and 
become  gradually  idiotic.  Finally,  they  die  in  a  comatose  stage. 
Through  removal  of  the  spleen  the  cachexia  comes  on  more 
quickly.  Klose  says  that  the  symptoms  after  removal  of  the 
thymus  are  due  to  a  poisoning  by  phosphorus.  If  the  thymus 
is  removed  in  the  early  weeks  of  a  dog's  life  there  are  decided 
changes  in  the  bone  through  diminished  calcification.  They 
grow  more  slowly,  have  weakness  of  the  muscles,  become  eas- 
ily tired;  fractures  heal  slowly,  the  extremities  are  bent,  and 
there  is  an  increased  loss  of  calcium. 

The  thymus  begins  to  regress  at  puberty.  This  alone 
points  toward  the  connection  of  the  thymus  with  the  genitalia. 
Individuals  with  hypoplastic  ovaries  retain  the  thymus  longer 
than  normal.  In  this  form  of  status  thymicus  there  is  a  ques- 
tion whether  the  thymus  is  in  direct  relation  with  the  genitalia 
or  whether  both  are  not  a  symptom  of  a  slow  development. 
Castration,  after  puberty  has  begun,  causes  an  increase  in  size 
of  the  thymus.  According  to  Hammar,  the  hyperplasia  of  the 
thymus  after  castration  is  not  compensatory,  but  Hammar 
believes  that  the  ovaries  and  adrenals  are  thymus  depressors, 
while  the  thyroid  (and  possibly  hypophysis  and  parathyroids) 
are  exciters  of  the  thymus. 

Blundel  considers  chlorosis  an  auto-intoxication  by  prod- 
ucts of  metabolism,  which  in  childhood  are  destroyed  by  the 
thymus  and  in  the  later  years  by  the  ovaries.  If  the  thymus 
stops  its  action  at  a  too  early  age,  and  the  ovary  begins  its 
work  too  late,  then  in  the  interval  the  organism  is  poisoned. 
Blundel  has  had  excellent  results  with  preparations  of  thymus. 
Novak  is  skeptical  about  this  theory.  Status  thymicus  (sudden 
death)  is  often  associated  with  a  large  thymus,  and  formerly 
this  sudden  death  was  attributed  to  thymic  asthma,  but  in 
sudden  death  in  status  lymphaticus  there  is  no  narrowing  or 


INTERNAL    SECRETIONS  95 

closure  of  the  trachea.  The  condition  is  really  due  to  primary 
heart-failure.  In  these  cases  there  is  a  general  enlargement 
of  the  lymph  glands,  of  the  tonsils,  of  the  follicles  at  the  base 
of  the  tongue  and  in  the  intestines,  enlargement  of  the  spleen, 
large  thymus,  narrow  aorta,  large,  soft,  pale  heart.  These 
patients  stand  narcosis  poorly  and  have  a  deficient  develop- 
ment of  the  "chromaffin  system."  It  becomes  easily  tired, 
this  important  system  does,  at  least  in  cases  of  sudden  death. 
Death  occurs  by  sudden  exitus  in  individuals  who  have  the 
not  infrequent  combination  of  Basedow's  disease  and  status 
thymicus.  Individuals  with  a  lymphatic-chlorotic  constitution 
show  a  remarkably  slight  resistance  toward  infectious  diseases. 
The  diagnosis  in  certain  cases  concerns  individuals  with  a  pasty 
look,  enlarged  glands  of  the  neck,  hyperplasia  of  the  tonsils, 
hypertrophy  of  the  left  ventricle,  enlarged  spleen,  and  a  ten- 
dency to  eczema.  In  collapse  the  only  treatment  consists  of 
mtracardial  injection  of  adrenalin.  This  is  the  ideal  treatment 
for  producing  heart  excitation  and  also  in  eventual  collapse 
of  the  chromaffin  system.     (Biedl.) 

After  a  short  period  of  development,  until  about  the  sec- 
ond year  of  life,  retrogressive  changes  occur  in  the  thymus. 
Involution  coincides  normally  with  adolescence.  There  may, 
however,  be  the  so-called  persistent  thymus.  Removal  of  the 
sex  glands  of  rabbits  is  followed  by  hypertrophy  of  the 
thymus.  If  thymectomy  is  performed  on  guinea-pigs  before 
puberty  there  results  a  rapid  development  of  the  ovaries.  The 
thymus  probably  exercises  an  inhibitory  influence  upon  the 
development  of  the  ovaries,  and  involution  of  the  thymus  is 
consequent  upon  the  maturity  of  the  sexual  glands.  In  thymec- 
tomized  animals  the  long  bones  take  longer  to  develop,  calci- 
fication progresses  slowly,  and  this  causes  retardation  of 
growth,  softness  of  bones,  and  imperfect  apposition  of  the 
periosteal  bony  layers  after  fracture. 

"The  thymus  gland  is  an  organ  of  importance.  Ex- 
tirpation at  the  height  of  its  development  results  finally  in 
death.  Most  probably  its  most  important  function  consists  in 
binding  acids,  thus  removing  injurious  substances   from  the 


96  THE    ENDOCRINES 

blood.  This  supposed  function  gives  us  an  explanation  for 
the  disturbances  occurring  in  the  calcium  metabolism  after  ex- 
tirpation of  the  organ,  for  the  changes  in  bone  and  in  the  cen- 
tral nervous  system.  The  thymus  gland  occupies  a  dominating 
position  over  the  lymphatic  apparatus.  Between  the  thymus, 
on  the  one  hand,  and  the  organs  of  internal  secretion  on  the 
other,  complex  relations  exist.  This  is  especially  true  of  the 
spleen.  This  organ  is,  so  to  speak,  'prepared'  by  the  thymus 
to  take  up  some  of  the  latter  organs'  still  unexplained  func- 
tions after  involution"  (Lampe). 

There  seems  to  be  a  close  relationship  between  the  thymus 
and  thyroid.  The  symptoms  of  exophthalmic  goiter  are  due 
to  either  an  excess  or  perverted  secretion  of  the  thyroid.  The 
primary  disturbance  exists  in  the  thymus,  the  action  of  the 
thyroid  being  that  of  a  "multiplicator,"  according  to  the  theory 
of  von  Mikulicz.  According  to  the  theory  of  Hart,  Basedow's 
disease  is  to  be  attributed  rather  to  hyperthymisation  than  to 
hyperthyroidism. 

Parathyroids 

Removing  the  parathyroids  produces  tetany.  Experi- 
ments on  pregnant  dogs  show  that  removal  of  the  parathyroids 
causes  tetany.  The  important  symptoms  consist  of  attacks 
of  tonic,  painful  contractions  or  cramps,  especially  in  the  ex- 
tremities. Associated  changes  are  trophic  disturbances,  es- 
pecially changes  in  ectodermal  structures,  such  as  loss  of  the 
hair,  brittleness  of  the  nails,  the  formation  of  cataract,  anoma- 
lies of  the  teeth,  looseness  of  teeth. 

The  parathyroids  in  pregnancy  show  hyperemia  and  evi- 
dences of  increased  activity.  Tetany  in  the  pregnant,  parturient 
and  nursing  woman  does  occur.  Cases  of  maternity  tetany  are 
characterized  by  the  severity  of  the  attacks,  the  spreading  of 
the  attacks  to  many  groups  of  muscles,  and  the  very  intense 
pain.  The  attacks  do  not  last  long.  Neumann  was  the  first 
who  showed  that  the  attacks  may  be  started  by  uterine  con- 
tractions. Attacks  may  occur  during  curettage,  whether  the 
patient  be  pregnant  or  not ;  that  is  during  simple  curettage  or 


INTERNAL    SECRETIONS  97 

curettage  for  miscarriage.  It  may  be  stated  that  in  all  those 
cases  of  tetany  which  occurs  in  pregnancy  there  are  changes 
in  the  parathyroids,  the  cause  of  which  dates  back  a  long  time, 
Since  in  many  cases  evidences  of  the  failure  of  parathyroid 
secretion  first  become  manifest  during  pregnancy,  it  is  prob- 
able that  pregnancy  makes  increased  demands  on  these  struc- 
tures. What  is  known  as  regards  the  etiology  may  be  summed 
up  in  the  observation  that  certain  classes,  such  as  tailors  and 
shoemakers,  are  especially  liable. 

Tetany  of  the  pregnant  woman  exerts  an  unfavorable  in- 
fluence on  the  fetus.  As  a  general  rule,  gravidity  tetany  is  a 
severe  illness.  In  severe  cases  of  tetany  in  pregnancy  the  con- 
dition should  be  interrupted.  Tetany  has  a  tendency  to  recur, 
and  Frankl-Hochwart  believes  that  future  pregnancy  should 
be  prohibited. 

The  parathyroids  have  been  said  to  stand  in  relation  to 
eclampsia  and  osteomalacia.  The  clinical  picture  of  eclampsia 
is  so  absolutely  different  from  that  of  tetany  that  only  an 
associated  etiologic  connection  seems  possible.  On  the  other 
hand,  it  is  possible  that  the  parathyroids  stand  in  relation  to 
osteomalacia.  Just  in  what  way  these  bodies  act  upon  the 
calcium  metabolism  is  not  known,  but  their  influence  upon 
the  calcium  deposits  in  bone  and  teeth  is  not  to  be  denied.  It 
must  be  recalled  that  attacks  of  tetany  may  be  followed  by 
loss  of  hair  and  the  nails.  (In  the  course  of  the  tetanic  attacks 
ergotin  and  chloroform  should  not  be  used.)  Erdheim  found 
in  six  cases  of  osteomalacia  evidences  of  a  former  hyper- 
function  of  these  glands.  He  does  not  consider  the  changes  in 
the  parathyroids  to  be  the  cause,  but  only  a  symptom  of  osteo- 
malacia. In  unison  with  this  opinion  may  be  cited  the  cases 
where  osteomalacia  and  tetany  occur  at  the  same  time  (Joseph 
Novak). 

Partial  removal  of  the  parathyroids  in  carnivorse  always 
shows  more  or  less  severe  symptoms  of  tetany  which  later  dis- 
appear. If,  after  partial  removal  of  the  parathyroids,  no  symp- 
toms appear,  the  animal  is  in  the  condition  known  as  latent 
tetany.     Such  animals  as  appear  sound  after  removal  of  two 


98  THE    ENDOCRINES 

or  three  parathyroids  are  attacked  by  tetany  when  they  become 
pregnant,  or  if  injected  with  placental  extract.  In  other  words, 
a  metabolic  derangement  causes  the  symptoms  of  tetany  to 
appear  where  they  were  previously  latent.  Every  acute  tetany 
is  accompanied,  in  addition  to  the  nervous  symptoms,  by  sec- 
ondary signs,  such  as  shaggy  appearance  of  the  coat,  falling  of 
the  hair,  eczema,  and  extreme  emaciation. 

The  acute  nervous  symptoms  coming  on  after  removal  of 
the  thyroid  occur  only  where  the  parathyroids  are  also  re- 
moved. This  condition,  known  as  tetany  (characteristic  mus- 
cular convulsions),  is  due  to  suppression  of  the  function  of  the 
parathyroid,  and  is  called  tetania  parathyropriva.  Milder  forms 
exist  and  also  a  latent  tetany  characterized  by  hypersensibility 
of  the  nerves,  a  state  occurring  frequently  after  partial  removal 
of  the  parathyroids. 

Cases  of  thyroidectomy  in  the  human  being  occasionally 
have  latent  tetany,  because,  when  pregnant,  tetany  develops. 
There  is  another  form,  known  as  maternity  tetany.  Tetany  is 
also  seen  in  infants.  There  is  an  intimate  relationship  between 
tetany  and  menstruation,  pregnancy  and  lactation.  Partial  re- 
moval of  the  parathyroids  in  animals,  as  stated  above,  may  be 
followed  by  a  tetany  provoked  by  pregnancy  or  lactation.  The 
teeth  of  people  who  have  had  infantile  tetany  show  hypoplasia 
of  the  enamel.  The  parathyroids  frequently  become  tuber- 
culous, and  the  Chvostek  phenomenon  in  tuberculosis  patients 
is  frequent.  Myasthenia  gravis  comes  from  increased  func- 
tion of  the  parathyroids.  (  ?)  Paralysis  agifans  comes  from 
too  little  parathyroids.  (?)  These  glands  are  supposed  to 
maintain  the  balance  of  neuromuscular  activity.  Myasthenia 
and  tetany  are  diametrically  opposed,  according  to  Chvostek. 
Tetany  is  produced  by  hypofunction,  while  myasthenia  is  pro- 
duced by  hyperfunction. 

The  extract  of  parathyroid  glands  increases  intestinal 
peristalsis  and  the  muscular  contractions  of  the  uterus  and 
increases  diuresis.  According  to  Kocher,  the  energetic  use  of 
thyroid  extract  and  of  iodothyrin  in  large  doses  abates  the 
symptoms  of  postoperative  tetany,  and  when  continued  stops 


INTERNAL    SECRETIONS  99 

the  attacks.  In  postoperative  tetany  the  improvement  is  im- 
mediate after  hypodermic  injection  of  soluble  thyroid  extract. 
It  is  not  probable  that  enough  parathyroid  substance  is  pres- 
ent in  the  extract  of  the  thyroid  glands  to  account  for  this 
effect.  There  are  numerous  accounts  of  the  favorable  effects 
of  thyroid  gland  extracts  in  the  parathyroid  tetany  of  animals. 
There  is  a  relationship  between  the  thyroid  and  the  para- 
thyroid. After  removing  the  parathyroids,  the  thyroid  often 
hypertrophies.  Thyroid  treatment  acts  well  in  parathyroid 
tetany.  There  is  a  parathyroid  hypertrophy  after  removal  of 
the  thyroid.  These  three  facts  speak  for  a  relationship.  The 
hypertrophy  of  one  group,  after  removal  of  the  other,  may  be 
regarded  as  compensatory.  Possibly  a  vicarious  activity  of  the 
thyroid  and  parathyroids  may  be  assumed.  Rudinger  believes 
the  thyroid  and  parathyroid  to  be  antagonistic.  He  believes 
that  the  function  of  one  gland  is  controlled  by  the  other,  and 
that  when  this  balance  is  disturbed  by  the  removal  of  one  the 
other  one  hypertrophies.  The  giving  of  parathyroid  glands 
was  followed  by  bad  symptoms  in  myxedema,  but  good  symp- 
toms resulted  in  Graves'  disease.  Rudinger  believes  that  the 
hyperfunction  of  the  thyroid  in  Graves'  disease  is  restrained 
by  giving  parathyroid  glands,  while  in  myxedema,  the  hypo- 
function  is  intensified.  He  believes  that  the  thyroid  secretion 
stimulates  the  sympathetic  nerves.  Removing  the  parathyroids, 
which  are  the  inhibitory  agent,  increases  the  sensibility  of  the 
sympathetic  nerves.  The  most  important  point  in  favor  of  the 
theory  of  antagonism  is  provided  by  the  hypertrophy  of  one 
gland  when  the  other  is  removed.  Parathyroid  tetany  may 
be  due  to  a  toxic  product  of  metabolism  or  to  the  presence  o£ 
a  toxin.  In  tetany  of  children  there  is  a  scarcity  of  calcium 
in  the  organism  of  children.  MacCallum  found  that  the  giv- 
ing of  a  five  per  cent,  solution  of  calcium  acetate  and  calcium 
lactate  by  mouth,  or  hypodermically,  or  intravenous,  to  dogs 
from  which  the  parathyroids  had  been  removed,  stopped  the 
tetanic  symptoms  for  twenty-four  hours.  The  parathyroid 
glands  possibly  control  the  calcium  metabolism.    Calcium  salts 


100  THE    ENDOCRINES 

exercise  an  inhibitory  effect  upon  pathologic  muscular  convul- 
sions (Biedl). 

The  parathyroids  have  much  to  do  with  the  absorption  and 
excretion  of  the  mineral  salts  of  the  body,  and  are  important, 
therefore,  to  the  nervous  system  and  the  bone.  Interference 
with  their  function  causes  a  decreased  resistance  to  infections. 
If  the  parathyroids  are  injured,  lactate  of  calcium  and  the 
feeding  of  parathyroid,  or  transplantation  of  parathyroid,  are 
necessary.  One-sixth  of  all  the  thyroid  cells  are  sufficient  for 
body  needs,  and  one  normal  parathyroid,  instead  of  the  four, 
suffices. 

Thyroid 

The  secretion  of  the  thyroid  gland  is  an  iodized  albuminoid 
which  modifies  the  activity  of  distant  organs  (hormone).  By 
increasing  normal  function  it  affects  the  metabolic  processes, 
cardiac  activity,  some  portions  of  the  sympathetic  system,  the 
hypophysis,  the  suprarenals.  Instances  of  its  activity  are  the 
promotion  of  skeletal  growth,  the  development  of  the  sex 
glands.  It  also  inhibits  function.  The  limitation  of  the  in- 
ternal secretory  function  of  the  pancreas  is  an  evidence  of 
its  inhibitory  power. 

The  arrest  of  growth  in  removal  of  the  thyroid  in  ani- 
mals is  due  to  a  retardation  of  the  process  of  ossification,  both 
of  the  epiphyses  and  of  the  synchondroses.  In  the  internal 
organs  there  results  an  enlargement  of  the  glandular  portion 
of  the  hypophysis.  In  addition  to  the  difference  in  skeletal 
growth,  there  is  general  apathy  and  atheromatous  degenera- 
tion of  the  aorta.  There  is  infantilism,  imperfect  activity  of 
the  sex  glands,  and  general  torpor.  The  animals  weigh 
one-third  as  much  only  as  they  should.  The  arrest  in  the 
growth  of  the  skeleton  and  the  development  of  the  sex  or- 
gans is  the  typical  and  invariable  result  of  the  absence  of  the 
thyroid  function  in  carnivorse  and  herbivorse.  In  older  animals 
the  changes  are  less  marked,  removal  causing  loss,  of  appetite, 
sluggish  digestion,  increased  emaciation,  and  finally  cachexia 
thyreopriva.      There   is   apathy,    trophic   disturbances   of  the 


INTERNAL    SECRETIONS  101 

cuticle,  falling  of  the  hair,  dryness  of  the  skin,  and  eczema. 
The  number  of  red  blood-cells  and  the  hemoglobin  are  de- 
creased, but  there  is  an  increasing  leukocytosis.  The  typical 
and  invariable  result  of  the  suppression  of  the  thyroid  function 
in  adult  animals  is  a  progressive  emaciation,  which  increases 
to  profound  cachexia  and  culminates  in  death.  The  most  char- 
acteristic post-mortem  finding  is  the  enlargement  of  the  hypo- 
physis (Biedl). 

The  same  changes  occur  in  human  beings  after  removal 
of  the  entire  thyroid.  This  is  the  so-called  cachcxia-striimu 
priva.  A  further  symptom  of  this  cachexia  is  a  diminution  of 
the  mental  energy,  of  the  energy  for  work,  and  a  typical 
edematous  swelling  of  the  skin. 

Lack  of  secretion  of  the  thyroid  in  infancy  produces  failure 
of  growth  and  development,  both  mental  and  physical.  The 
thyroid  is  a  necessary  element  in  promoting  growth  in  child- 
hood and  in  controlling  the  development  of  the  body  and  mind. 
It  rouses  mental  activity  and  is  a  cerebral  stimulant.  It  aids 
nitrogen  metabolism.  It  is  essential  in  its  relation  to  other 
secretions  in  providing  genital  development. 

In  congenital  myxedema  there  is  a  decided  inhibition  of 
growth.  There  is  obstinate  obstipation,  psychic  disturbances, 
and  a  marked  inhibiting  effect  on  the  sex  organs.  In  con- 
genital absence  of  the  thyroid  and  in  the  infantile  cases  of 
atrophy  of  the  thyroid,  which  atrophy  develops  in  the  fifth  and 
sixth  years,  the  large  majority  of  the  cases  are  found  in  female 
children. 

In  cretinism  the  genitalia  remain  of  the  infantile  type. 
The  secondary  sex  characteristics,  such  as  the  breasts  and 
the  hairing  of  the  mons  veneris,  are  very  slightly  developed. 
Myxedema  in  adults  is  more  frequent  than  infantile  myxedema. 
Myxedema,  cretinism,  cachexia  strumipriva  are  all  allied  con- 
ditions. 

The  thyroid  gland  is  very  active  at  puberty,  and  begins  to 
regress  at  the  so-called  climacteric  period.  In  old  age  the 
thyroid  becomes  atrophic.  The  falling  of  the  hair,  the  drop- 
ping of  the  teeth,  and  dry  and  wrinkled  skin,  the  lowered 


102  THE    ENDOCRINES 

temperature,  diminished  perspiration,  indolent  indigestion,  and 
consequent  emaciation,  reduced  metabolism,  and  consequent 
deposit  of  fat,  followed  by  emaciation,  decrease  of  mental  pow- 
er, and  the  diminution  of  the  activity  of  the  entire  nervous  sys- 
tem, these  are  all  symptoms  which  characterize  chronic  myxe- 
dema. 

Too  little  thyroid  is  responsible  for  some  cases  of  slow 
growth  in  children,  for  eczema,  some  cases  of  asthma,  perhaps 
amenorrhea,  disturbances  of  digestion,  states  of  depression  and 
of  melancholia,  myxedema,  etc.  also  the  dry  eczema,  and  itch- 
ing of  the  menopause  and  of  old  age. 

A  frequent  type  of  hypothyroidism  is  that  associated  with 
weight.  There  are  scanty  or  absent  menstruations,  deposit  of 
fat,  drowsiness,  slow  pulse,  dry  skin,  puffiness  of  the  body, 
puffiness  under  the  eyes,  the  type  that  I  have  called  phlegmatic. 

Under  the  title  of  "Chronic  Benign  Hypothyroidism"  is 
grouped  a  combination  of  symptoms,  such  as  loss  of  hair,  dim- 
inution of  the  perspiration,  changes  in  the  skin,  metrorrhagia. 
Other  cases  show  backache,  especially  in  the  morning,  without 
evident  changes  in  the  genital  organs,  and  also  metrorrhagia. 
Kocher  lays  stress  on  this  backache  as  due  to  hypothyroidism. 

Many  cases  of  hypothyroidism  are  psychopathic,  and,  as 
the  thyroid  is  influenced  by  mental  stimulation  and  mental  de- 
pression, mental  treatment  is  of  value. 

Hyposecretion  of  the  thyroid  may  cause  mental  depres- 
sion, from  simple  apathy  to  real  melancholia. 

Physically  there  Is  a  dryness  of  the  skin  and  hair,  the  skin 
does  not  perspire.  It  becomes  pigmented,  the  hair  falls  out  or 
becomes  gray.  The  surface  of  the  body  Is  cold,  the  hands  and 
feet  are  always  cold.  Appetite  and  digestion  are  impaired. 
There  is  an  Interference  with  the  calcium  metabolism.  There 
is  a  progressive  gain  In  weight.  There  may  be  constant  pain 
in  the  muscles  and  bones.  (Levi  of  Paris  says  that  in  many 
cases  of  "chronic  rheumatism"  thyroid  treatment  Is  the  best.) 
When  nervous  or  "neurasthenic  patients"  complain  of  such 
symptoms,  one  grain  of  thyroid  twice  a  day  added  to  the 
other  treatment  Is  of  value.     In  ten  days  the  effect  should  be 


INTERNAL    SECRETIONS  103 

evident  in  less  dryness  of  the  skin,  in  relief  from  the  sensation 
of  cold,  and  in  the  decided  improvement  of  mental  activity. 

In  hyperthyroidism  we  have  a  transient  or  continuous  over- 
secretion.  If  this  occurs,  and  the  body  cannot  neutralize  or 
destroy  it,  then  toxic  annoyances  of  various  degrees  occur. 

Congestive  goiter  shows  an  overfilling  of  the  blood-ves- 
sels and  occurs  during  menstruation  or  pregnancy,  because 
of  the  intimate  relation  which  exists  between  the  thryoid  and 
the  ovaries.  Retained  secretion  means  simple  goiter.  A  hyper- 
plasia and  an  increase  of  cells  in  the  parenchyma  mean  over- 
activity. 

There  is  a  close  relation  between  the  ovaries,  uterus,  and 
thyroid,  hence  the  goiter  of  adolescence  and  of  pregnancy.  In 
the  climacterium  this  relation  causes  changes  in  the  thyroid 
from  hyperthyroidism  to  hypothyroidism. 

The  relation  of  the  thyroid  to  the  ovary  sensitizes  the  thy- 
roid gland.  This,  coupled  with  the  various  changes  in  balance 
which  occur  at  puberty,  menstruation,  etc.,  is  responsible  for 
the  instability  which  produces  those  various  nerve  phenomena 
due  to  hypersecretion  or  hyposecretion,  or  variations  between 
the  two,  which  make  women  the  weaker  sex. 

The  comparative  frequency  with  which  Graves'  disease 
occurs  in  persons  with  status  thymicolymphaticus  is  probably 
something  more  than  coincidence.  On  the  one  hand,  there- 
fore, hyperthyroidism  leaves,  as  in  Graves'  disease,  changes  in 
the  functions  of  the  ovaries.  On  the  other,  primary  changes 
in  activity  of  the  sex  glands  may  exercise  a  secondary  in- 
fluence upon  the  thyroid,  and  as  a  result  symptoms  resembling 
those  of  Graves'  disease  are  produced. 

Symptoms  resembling  those  of  Graves'  disease  may  be 
associated  with  various  conditions,  as  chlorosis,  pseudochlorosis 
(swelling  of  the  thyroid,  increased  cardiac  activity,  mental  ex- 
citement, fatigue,  pallor,  without  chlorotic  changes  in  the 
blood).  Symptoms  resembling  Graves'  disease  are  often  seen 
at  the  climacterium.  The  remarkahle  incidence  of  Graves'  dis- 
ease in  ivomen,  and  the  frequency  zmth  which  its  occurrence  is 


104  THE    ENDOCRINES 

associated  with  functional  change  of  the  sex  glands,  are  fac- 
tors of  significance. 

There  may  be  paroxysmal  attacks  of  hyperthyroidism 
resembHng  very  mild  attacks  of  parathyroid  tetany.  Attacks 
may  be  associated  with  weakness,  dizziness,  blueness,  very  rapid 
and  feeble  pulse,  and  symptoms  resembling  collapse.  Patients 
appear  very  sick.  There  may  be  associated  diarrhea  and  un- 
controlled movements  of  the  hands  and  extremities.  These 
attacks  may  come  on  during  nursing,  or  after  fatigue  or  irri- 
tations of  various  sorts.  Such  patients,  aside  from  these  at- 
tacks, have  a  marked  tendency  to  premenstrual  annoyances 
of  the  type  resembling  hyperthyroid  symptoms. 

Hyperthyroidism  is  either  an  excess  of  thyroid  or  a  dys- 
thyroidism,  and  this  question  is  not  settled  yet.  In  most  cases 
there  are  evidences  of  hyperplasia  in  the  gland,  yet  the  condi- 
tion may  be  one  of  perverted  function  rather  than  oversecre- 
tion. 

In  all  cases  of  hyperthyroidism  the  pulse-rate  and  the 
heart  action  are  practically  increased.  I  scarcely  ever  make 
such  a  diagnosis  without  it.  I  usually  rely  on  a  slow  pulse  for 
the  diagnosis  of  hypothyroidism. 

The  vasomotor  changes  of  hyperthyroidism  produce  a 
sense  of  warmth  which  is  relieved  subjectively  in  cold  weather. 
On  the  other  hand,  a  marked  sensitiveness  to  cold  speaks  for 
hypothyroidism. 

Tremor  is  usually  present  in  hyperthyroidism.  Exoph- 
thalmos is  not  due  to  the  hyperthyroidism,  but  probably  to  the 
irritation  of  the  hypophysis  often  associated  with  the  thyroid 
affection.  In  Basedow's  disease  there  is  generally  an  increase 
of  mononuclear  cells.  Berry  states  that  exophthalmos  is  due 
to  accumulation  of  fat  in  the  orbit. 

The  relationship  between  Basedow's  disease  and  the 
female  sexual  sphere  is  indicated  by  the  frequency  with  which 
this  disease  develops  during  the  sexually  active  years. 
Amenorrhea  is  considered  a  frequent,  even  if  not  constant, 
symptom  of  the  disease.     The  ability  to  conceive  is  decidedly 


INTERNAL    SECRETIONS  105 

diminished.  The  disease  is,  as  a  rule,  unfavorably  influenced 
by  pregnancy. 

The  thyroid  undersecretes  in  many  cases  at  first,  producing 
perhaps  physical  weakness,  tendency  to  fatigue,  diminished 
sweating,  loss  of  hair.  It  is  possible  that  such  evidences  of 
diminished  thyroid  function,  asociated  in  some  cases  with 
muscular  and  joint  pains,  may  precede  or  end  in  or  complicate 
a  change  from  hypofunction  to  hyperfunction.  Involvement 
of  the  thyroid  may  be  due  to  tuberculosis,  tonsilitis,  influenza, 
typhoid,  lues,  staphylococcus  infections,  etc.  In  other  words, 
a  lesion  produced  in  the  thyroid  and  resulting  in  lowered  energy 
of  the  gland  in  part,  leads  to  an  attempt  at  compensation,  and 
results  in  symptoms  quite  different  from  the  early  ones  of  de- 
pression. This  view  of  hypothyroidism,  associated  with  the 
early  stages  of  hyperthyroidism,  may  account  for  the  improve- 
ment obtained  by  thyroid  treatment  or  by  the  use  of  iodin  in 
cases  of  apparent  hyperthyroidism  (Dock). 

Simple  goiter  may  develop  into  Basedow's  disease  through 
the  use  of  iodids  or  iodothyrin,  through  the  influence  of  puber- 
ty, pregnancy,  menopause,  and  other  strains.  Basedow's  may 
degenerate  into  true  myxedema.  Sometimes  symptoms  of 
Basedow's  disease  and  of  myxedema  may  exist  together.  This 
means  that  the  greater  part  of  the  gland  is  inactive,  and  that 
what  remains  active  secretes  an  abnormal  product,  producing 
intoxication. 

Basedow's  disease  seems  to  have  a  tendency  to  be  trans- 
mitted, and  in  families  of  such  patients  there  is  a  tendency  to 
neuroses,  psychoses,  and  diabetes. 

Thyroidectomy  in  animals  does  not  produce  glycosuria. 
Adrenalin  injections,  which  in  normal  animals  provoke  extreme 
glycosuria  together  with  an  increased  metabolism  of  albumin 
in  the  fasting  state,  do  not  produce  glycosuria  in  thyroidecto- 
mized  animals,  even  when  sugar  is  given  at  the  same  time. 
Adrenalin  produces  in  dogs,  from  which  both  thyroid  and 
parathyroid  have  been  removed,  a  marked  glycosuria,  more 
so  than  in  normal  animals.  The  effect  upon  metabolism  of 
the  suppression  of  parathyroid  function  is  the  reverse  of  that 


106  THE   ENDOCRINES 

produced  by  the  suppression  of  the  thyroid,  for,  in  true  athyreo- 
sis,  the  assimilation  of  sugar  is  increased  and  the  use  of  adre- 
nalin is  not  followed  by  glycosuria. 

The  relationship  between  the  thyroid  and  the  metabolism 
of  the  carbohydrates  suggests  that  this  relation  depends  upon 
the  pancreas.  The  thyroid  is  believed  to  promote  the  activity 
of  the  chromaffine  (adrenal)  system  and  to  inhibit  that  of  tho 
pancreas.  The  direct  results  of  thyroidectomy  consist  in  re- 
duction of  the  metabolism  of  albumin,  fat,  and  salt.  The  in- 
direct results  include  a  hyperactivity  of  the  pancreas,  due  to 
the  removal  of  the  inhibitory  agent.  The  thyroid,  the  chro- 
maffine system,  and  the  infundibular  portion  of  the  hypophysis 
accelerate  the  process  of  metabolism.  The  pancreas  and  the 
parathyroids  retard  metabolism.  There  is  a  normal  balance 
between  the  two,  as  a  rule. 

If  thyroid  extract  or  iodothyrin  are  given  continuously 
for  two  or  three  weeks,  the  amount  of  CO2  excretion  will  be 
increased  20  per  cent.  Thyroid  extract  has  the  effect  of  in- 
creasing the  capacity  for  nervous  reaction  and  giving  greater 
energy  to  phlegmatic  people.  It  reduces  constitutional  obesity, 
but  not  obesity  due  to  overfeeding  (Biedl). 

The  flooding  of  the  organism  with  thyroid  substances 
exercises  an  elective  stimulating  effect  upon  the  sympathetic, 
and  it  also  influences  the  activity  of  those  other  internal  secre- 
tory organs  which  have  functional  interrelationship  with  the 
thyroid  (thymus,  hypophysis,  suprarenals,  ovaries.)  Amenor- 
rhea is  sometimes  benefited  by  thyroid,  especially  if  there  are 
other  symptoms  of  insufficient  thyroid  secretion,  such  as  weight 
and  dryness  of  the  skin.  Administration  of  thyroid  is  sup- 
posed to  stimulate  bleeding  by  causing  a  dilatation  of  the  blood- 
vessels, especially  in  the  uterus  and  nose  (Osborne),  yet,  on 
the  other  hand,  the  giving  of  thyroid  diminishes  the  bleeding, 
especially  in  hemophilia. 

It  is  said  by  some  that  insufficiency  of  the  thyroid  may 
cause  hemorrhage,  and,  on  the  other  hand,  it  is  claimed  that 
too  much  of  its  secretion  may  also  cause  hemorrhage.  Too  much 


INTERNAL    SECRETIONS  107 

thyroid  increases  the  coagulation  time  of  the  blood.    Too  little 
thyroid  diminishes  the  coagulation  time  of  the  blood. 

We  should  not  forget  that  cases  zvhich  simulate  Bright's 
disease  may  he  simply  cases  n^hich  need  thyroid. 

Hypophysis — Pituitary 

It  appears  from  modern  investigations  that  the  hypophysis 
plays  a  part  in  the  human  economy,  from  childhood  up,  which 
is  of  great  importance  in  the  way  of  skeletal  grozvth,  mental 
development,  genital  development,  sugar  tolerance,  etc.  It 
produces,  by  its  over-secretion,  or  under-secretion,  most  per- 
manent and  lasting  changes  in  the  bony  structure  of  the  body, 
in  the  laying  up  of  fat,  and  influences  to  a  decided  degree  th^ 
mental  and  nervous  make-up  of  the  individual. 

The  hypophysis  is  composed  of  an  anterior  and  posterior 
part.  The  anterior  seems  to  be  concerned  with  processes  of 
growth,  the  posterior  seems  to  be  concerned  with  metabolism, 
especially  with  that  of  sugar.  If,  in  the  growing  child,  the 
hypophysis  fails  to  perform  its  functions,  there  is  a  failure  in 
bone  stimulation  and  tissue  growth,  there  is  a  failure  in  bony 
development,  and  the  individual  may  become  a  dwarf.  If  the 
anterior  lobe  of  the  hypophysis  functionates  and  secretes  too 
actively  during  the  years  of  growth,  the  skeleton  becomes  larger 
than  normal,  and  if  the  process  continues  in  the  pre-adolescent 
stages,  the  individual  becomes  a  giant.  It  can  be  readily  seen 
that  this  tendency  to  become  a  giant  exists  so  long  as  com- 
plete ossification  of  the  epiphyses  has  not  taken  place.  After 
the  individual  has  attained  his  full  growth  in  a  normal  man- 
ner, and  after  ossification  of  the  epiphyses  has  occurred,  over- 
activity of  the  anterior  lobe  stimulates  bone  growth,  but  not 
in  the  way  of  general  increase  in  stature,  for  that  is  now  no 
longer  possible.  It,  however,  produces  changes  in  the  bones 
of  the  face  and  hands  and  feet,  producing  the  condition  known 
as  acromegaly.     So  much  for  the  anterior  lobe. 

The  posterior  lobe  is  concerned  with  the  metabolism  of 
sugar.  If  there  is  failure  of  function  on  the  part  of  this  lobe, 
there  is  a  tendency  to  gain  in  weight,  and  at  any  period  of  life 


108  THE    ENDOCRINES 

adiposity  may  result.  In  the  young  growing  child  there 
is  then  a  diffuse  accumulation  of  fat  over  the  entire  body. 
If  in  the  adult  the  same  change  occurs,  the  adiposity  which 
is  thus  associated  with  lack  of  function  of  the  posterior  lobe 
has  the  name  dystrophia  adiposo-genitalis,  because  the  hy- 
pophysis has  a  decidedly  close  relation  to  the  development 
and  preservation  of  the  genitalia.  In  the  younger  years,  be- 
fore adolescence,  anomalies  of  the  hypophysis,  as  a  rule,  cause 
failure  of  development  of  the  ovaries  and  of  the  uterus  and  of 
the  other  structures  characteristic  of  the  female.  After 
adolescence  anomalies  of  the  hypophysis  result  in  atrophy  of 
the  genitalia.  The  same  thing,  lack  of  development  of  the 
genitalia,  is  true  with  giants  and  dwarfs.  In  the  one  case 
there  is  too  little  secretion,  in  the  other  there  is  too  much,  and 
yet  with  either  of  these  alterations  genital  dystrophy  may 
occur.  The  same  genital  change  holds  true  in  acromegaly.  In 
fact,  so  pronounced  are  the  changes  in  the  ovaries  with  this 
latter  condition  that,  in  the  minds  of  many  investigators,  hypo- 
function  of  the  ovaries  has  been  considered  the  primary  factor 
in  causing  the  changes  in  the  hypophysis  which  are  responsible 
for  acromegaly. 

Changes  in  the  secretion  and  functions  of  the  hypophysis 
have  other  effects  than  on  growth  and  stature,  than  on  the 
genitalia,  than  on  the  accumulation  of  fat  and  the  metabolism 
of  sugar.  Changes  in  the  secretion  of  the  hypophysis  are  as- 
sociated with  alterations  in  other  gland  functions  in  the  body. 
The  relationship  of  the  hypophysis  to  the  adrenals,  the  pancreas, 
the  thyroid,  etc.,  is  very  close,  but  not  so  intimate  as  with  the 
ovaries.  The  relationship  of  hypophysis  to  the  psyche  is  close, 
for  the  various  forms  of  hypophysis  disease  may  produce 
nervous  annoyances  and  psychic  manifestations  and  states  re- 
sembling "hysteria,  neurasthenia,"  etc. 

Tumors  of  the  hypophysis  are  frequently  the  cause  of 
these  diseases.  In  some  cases  they  cause  too  much  secretion, 
and  in  some  cases  they  are  responsible  for  a  diminished  secre- 
tion. In  addition,  they  may  produce  symptoms  due  to  their 
size  and  to  the  pressure  which  they  produce  within  the  cerebrum 


IXTERXAL    SECRETIOXS  109 

and  on  other  nerve  tissue.  But,  aside  from  this,  functions  of 
the  hypophysis  are  akered  and  interfered  with,  without  the 
presence  of  tumors.  It  seems  that  infections,  intoxications, 
diseases  of  other  glands,  pregnancy,  menopause,  and  other 
states  produce  structural  or  functional  alterations  in  the  hypo- 
physis, as  they  do  in  any  or  all  of  the  other  glands. 

It  must  be  remembered  that  either  lobe  may  be  involved 
independently  of  the  other,  or  that  both  may  be  affected  at 
the  same  time.  Either  may  be  oversecreting,  or  undersecreting, 
without  regard  to  the  changes  occurring  in  the  other  portion. 
In  this  way  various  combinations  of  phenomena  and  symptom? 
may  be  produced,  involving  bony  growth,  stature,  accumula- 
tion of  fat,  alterations  of  temperature  and  pulse,  changes  in 
the  other  glands,  psychical  alterations,  etc.,  resulting  in  symp- 
toms which  can  l)e  classified  under  no  definite  heading,  but 
which  require  patience  and  attention  to  eventually  diagnose 
and  treat. 

Hypopituitarism. — We  may  have  hypopituitarism  orig- 
inating before  adolescence  or  originating  after.  If  hypopitui- 
tarism predominates,  there  results  adiposity  with  skeletal  and 
sexual  infantilism  in  childhood  (Frohlich).  Adiposity  with 
sexual  infantilism  of  the  reversive  type  results  when  hypo- 
pituitarism originates  in  the  adult.  The  posterior  lobe  secre- 
tion possibly  discharges  into  the  cerebrospinal  fluid.  The  an- 
terior lobe  discharges  secretory  products  into  the  blood  stream. 
The  anterior  part  is  more  closely  related  to  other  glands,  but 
controls  skeletal  growth.  Posterior  lobe  is  more  closely  allied 
to  tissue  metabolism,  and  to  the  activity  of  the  renal  and  vascu- 
lar svstems.  Xormal  posterior  lobe  activity  is  essential  to 
carbohydrate  metabolism.  A  diminution  of  this  secretion  leads 
to  a  high  tolerance  for  sugars,  with  a  resultant  accumulation 
of  fat.  In  the  majority  of  cases  of  adiposity  there  seems  to 
be  incomplete  metabolism.  The  ineffectual  burning  up  of  the 
carbohydrates  causes  subnormal  temperature.  This  is  also 
common  to  insufficiency  of  the  thyroid  and  adrenals. 

!Many  cases  of  infantilism  are  due  to  a  primary  thyroid 
insufiticiency.     "]Many  cases  regarded  primarily  as  of  thyroid 


110  THE    ENDOCRINES 

origin,  especially  cretinoid  states,  may  actually  be  due  to  de- 
fective hypophyseal  activity,  which  is  often  associated  with 
actual  enlargement  of  the  thyroid."  Many  types  of  skeletal 
undergrowth,  as  we  know  from  the  action  of  the  anterior  lobe 
in  processes  of  growth,  are  due  to  hypophysis  rather  than  thy- 
roid. Hypophyseal  cretinism  and  infantilism  are  recognizable, 
clinical  entities.  Adiposis  dolorosa  is  probably  disturbed 
metabolism,  secondary  to  disease  of  the  ductless  glands.  Thy- 
roid extract  is  actually  of  benefit  in  cases  of  hypophyseal  obes- 
ity. Most  cases  of  undoubted  hypopituitarism  have  exhibited 
some  degree  of  psychic  disturbance,  varying  from  nervousness 
to  epilepsy  and  actual  mental  derangement.  Pituitary  deficien- 
cy, like  thyroid  deficiency,  may  cause  signs  of  mental  instabil- 
ity without  encephalic  lesion.  "And  there  can  be  little  doubt 
but  that  many  of  the  psychasthenias  and  neuroses  of  one  sort  or 
another  will  prove  to  be  associated  with  ductless  gland  dis- 
turbances, more  particularly  with  those  of  hypophyseal  origin" 
(Gushing). 

A  powerful  galactogogue  substance  exists  in  the  posterior 
lobe.  The  posterior  lobe  extracts  have  a  specific  action  on 
smooth  muscle  (and  especially  on  uterine  fibers),  and  ex- 
press the  milk. 

In  preadolescent  hypopituitarism  there  is  a  tendency 
toward  persistence  of  sexual  infantilism  and  an  imperfect  or 
delayed  acquirement  of  the  so-called  secondary  sex  charac- 
teristics, just  as  in  hyperpituitarism  after  puberty  there  is  a 
tendency  to  testicular  hypoplasia,  impotence,  amenorrhea,  and 
some  loss  of  secondary  characteristics. 

In  pregnancy  the  pars  anterior  shows  a  multiplication  of 
large  neutrophilic  elements,  which  are  apparently  derived  from 
the  normal  cells  (Hauptzellen).  After  labor  the  gland  in- 
volutes, but  never  goes  back  to  its  previous  size.  This  change, 
occurring  in  successive  pregnancies,  may  bring  about  a  physi- 
ologic inactive  condition  of  the  gland,  and  may  produce  the 
adiposity,  loss  of  hair,  asthenia,  subnormal  temperature,  often 
seen  after  many  pregnancies.  On  the  other  hand  overactiv- 
ity may  persist,  leading  first  to  acromegalic  changes  with  final 


INTERNAL    SECRETIONS  111 

insufficiency.  The  interstitial  cells  of  the  genital  glands  and 
the  corpus  luteum  exercise  an  important  role  in  interglandular 
relations. 

This  hypophysis  gland  reacts  normally  to  bacterial  intoxi- 
cation, and  animals  subjected  to  a  partial  hypophysectomy  are 
extremely  susceptible  to  infections,  so  that  it  is  evident  that 
the  gland  secretes  some  protective  substances. 

With  inefficiency  of  the  hypophysis,  somnolence  is  notice- 
able, just  as  in  hibernation.  There  is  a  tendency  toward  great 
sleep,  subnormal  temperature,  slow  pulse,  lowered  metabolism, 
a  definite  hypesthesia  of  the  body  to  painful  stimuli,  and  a 
hypoplasia  of  the  sexual  glands. 

Hypopituitarism. — After  a  complete  removal  of  the 
hypophysis,  a  subcutaneous  or  intravenous  injection  of  the 
emulsion  of  a  single  fresh  gland  would  temporarily  arouse  to 
apparently  normal  activity  a  somnolent  animal  in  whom  a 
subnormal  temperature  betrayed  the  onset  of  a  cachexia  hypo- 
physeopriva. 

The  manifestations  of  glandular  deficiency,  whether  or 
not  they  are  accompanied  by  pressure  symptoms  or  by  evidences 
of  pre-existent  overactivities,  with  more  or  less  marked  over- 
growth, are  (Gushing)  : 

A  tendency  to  subnormal  temperature. 

Dry  skin. 

Loss  of  hair. 

A  slow  pulse. 

A  lowered  blood  pressure. 

Asthenia. 

Increased  assimilation  limits  for  carbohydrates. 

Often  associated  with  a  tendency  to  adiposity. 

Obstipation. 

Polyuria. 

Psychoses. 

Tendency  to  epileptiform  seizures. 

"The  malady  is  a  polyglandular  one,  and  hence,  In  addi- 
tion to  hypophysis,  may  be  helped  by  other  glands,  such  as 
adrenal  and  thyroid.    Even  after  a  year  of  glandular  feeding, 


112  THE    ENDOCRINES 

amenorrhea  may  be  relieved  and  libido-et-pofentio  sexualis  may 
be  restored.  It  only  rarely  has  a  marked  effect  on  obesity. 
A  combination  of  thyroid  and  hypophysis  may  stimulate  tissue 
katabolism.  Hypophysis  extract  may  produce  mental  and 
physical  rejuvenation;  raises  body  temperature,  raises  blood- 
pressure,  benefits  obstipation,  removes  the  drowsiness,  improves 
mental  activity,  on  the  use  of  several  grains  of  the  dried  whole- 
gland  preparation  three  times  a  day.  In  some  cases  it  works 
beautifully  by  hypodermic  use. 

"Adipositas  dolorosa,  universalis,  and  dystrophia  adipose- 
genitalis  are  due  to  posterior  lobe  deficiency.  To  this  symp- 
tom-complex of  adiposity  is  added  high  sugar  tolerance,  sub- 
normal temperature,  slowed  pulse,  asthenia,  drowsiness,  all 
due  to  deficiency  of  the  posterior  lobe.  The  reverse  condition 
follows  on  posterior  lobe  administration;  namely,  emaciation, 
spontaneous  glycosuria,  slightly  elevated  temperature.  This 
may  be  produced  by  injections  or  by  administering  gland  prep- 
arations by  mouth.  The  adiposity  of  hypopituitarism  is  a  gen- 
eralized one,  invading  other  organs,  too,  such  as  the  liver. 
Increased  deposition  of  fat  may  occur,  also  with  deficiencies  on 
the  part  of  the  sex  glands,  the  thyroid,  and  possibly,  too, 
the  pineal  and  adrenal." 

"Insufficiency  of  the  posterior  lobe  may  be  associated  with 
stimulation  or  inhibition  of  the  anterior  lobe;  hence,  coupled 
with  obesity,  we  may  have  the  combination  of  overgrowth 
with  sexual  precocity  or  the  reverse,  or  undergrowth  with 
sexual  precocity  or  the  reverse.  (The  sexual  precocity,  I  think, 
may  depend  on  other  elements.)  Hypertrichosis,  adiposity, 
pigmentation,  high  blood-pressure,  may  be  due  to  hyperadre- 
nalism.  Precocious  sexual  development,  overgrowth,  adipos- 
ity, may  be  due  to  hyperpinealism." 

Dercum's  disease  means  adiposity,  tenderness  and  pain, 
asthenia,  psychosis. 

"Extracts  of  the  posterior  lobe  possess  diuretic  properties. 
The  administration  of  posterior  lobe  extract  causes  an  increase 
in  the  urinary  output.  A  hormone  in  the  pars  nervosa  activates 
renal  secretion.     There  is,  therefore,  difficulty  in  explaining 


INTERNAL    SECRETIONS  113 

the  diuresis  which  accompanies  hypopituitarism,  for  one  would 
expect  these  individuals  to  show  a  lowered  urinary  output. 
Some  of  the  cases  constitute  almost  a  diabetes  insipidus.  In 
experimental  hypophysectomy  the  amount  of  urine  in  animals 
increases  to  2000  c.c.  in  twenty-four  hours"   (Gushing). 

Blood-pressure. — "Hypopituitarism  means  low  arterial 
tension,  often  below  100.  When  patients  complain  of  asthenia, 
also,  the  pressure  may  be  down  to  70.  Even  in  some  cases, 
where  the  anterior  lobe  was  still  hyperactive,  the  pressure  was 
low.  There  are  some  exceptions  as  regard  low  pressure  with 
insufficiency,  for  the  tension  may  be  high.  The  low  pressure 
with  asthenia  and  pigmentation  suggests  that,  even  when  the 
malady  is  hypophyseal,  a  secondary  change  in  the  adrenals,  in 
the  way  of  inactivity,  may  be  responsible  for  these  symptoms." 

Low  blood-pressure  is  present  with  hypopituitarism. 
Many  acromegalics  have  a  slight  eosinophilia. 

Hyperpituitarism. — If  hyperpituitarism  predominates 
there  is  overgrowth,  resulting  in  gigantism  when  the  process 
antedates  ossification  of  the  epiphyses  (Launois)  ;  acromegaly 
when  the  process  occurs  after  ossification.  Hypophysis  hyper- 
activity before  adolescence  and  before  ossification  produces 
large  stature;  after  ossification  it  produces  acromegaly. 

To  cause  skeletal  undergrowth,  glandular  insufficiency 
must  have  been  evident  before  full  stature  is  attained ;  that  is, 
before  adolescence,  though  hypopituitarism  later  will  dwarf 
the  stature.  That  Is  likewise  true  In  deficiency  of  the  thyroid, 
the  adrenals,  and  In  alteration  of  the  thymus. 

There  is  one  certain  experimental  method  of  inciting 
skeletal  overgrowth,  and  that  is  by  early  castration. 

The  hypertrophic  enlargement  of  the  hypophysis  gland,  or 
the  histologic  hyperplasia,  are  primary  in  the  case  of  acromegaly 
and  gigantism,  but  are  secondary  In  the  case  of  eunuchism. 

Hypophyseal  hyperplasia  Is  responsible  for  the  rapid  body 
growth  which  normally  occurs  at  puberty.  An  exaggeration 
of  the  growth  produces  what  is  known  as  a  "normal  giant," 
an  Individual  normally  proportioned,  sexually  intact,  with  great 
physical  strength.     If  this  growth  ceases  for  a  time,  then  sub- 


114  THE   ENDOCRINES 

sequent  hyperplasia  will  produce  acromegaly  if  ossification 
has  taken  place.  As  stated,  acromegaly  occurs  if  there  is  an 
interval  between  the  two  stages  of  hyperplasia.  (An  early 
postadolescent  period  of  hyperpituitarism  leads  to  physiologic 
overgrowth  or  normal  gigantism.) 

Many  cases  of  hyperplasia  show  quiescent  periods,  after 
which  recrudescences  may  occur.  In  other  cases  the  process  is 
permanently  checked,  the  clinical  traces  of  skeletal  overgrowth 
being  the  only  evidence.  In  others  there  results  a  change  to 
glandular  insufficiency,  as  the  result  of  involution  which  may 
follow  on  the  process  of  hyperplasia.  The  early  growing  child 
may  show  only  coarseness  of  the  tissues  or  other  minor  signs 
of  a  mild  hyperplasia  (Gushing). 

"A  spontaneous  mellituria,  even  of  such  a  degree  as  to 
simulate  diabetes  and  to  be  accompanied  by  furunculosis,  is  not 
uncommon  in  acromegaly  and  gigantism,  and,  I  presume, 
that  during  the  actual  period  of  hyperpituitarism  a  low  sugar 
tolerance,  if  not  actual  glycosuria,  is  probably  found  in  all 
cases.  Glycosuria  is  only  a  temporary  symptom,  and  a  giant 
or  acromegalic  may  be  in  an  active,  quiescent  or  retrogressive 
stage  of  hyperpituitarism,  and  hence  metabolism  changes  ac- 
cordingly. The  changes  differ  as  much  in  the  early  and  late 
stages  of  acromegaly  as  occurs  between  "Graves'  disease  and 
myxedema"  (Gushing). 

Whether  obesity  from  castration  may  not  occur  through 
the  resultant  diminution  of  the  ovarian  function,  or  whether, 
contrariwise,  the  obesity  of  castration  may  not  occur  through 
the  associated  change  in  hypophysis  and  thyroid  activity,  can- 
not be  settled.  Whether  the  obesity  of  castration  is  due  to  the 
fact  that  the  hypophysis,  in  spite  of  its  hypertrophy,  or  because 
of  an  insufficient  hypertrophy,  does  not  make  up  for  the  loss 
of  the  ovarian  secretion,  is  to  be  cleared  up  in  the  future. 

There  are  certainly  puzzles  in  this  question.  That  condi- 
tions which  are  to  be  referred  to  increased  activity  of  the  hypo- 
physis, such  as  acromegaly  on  the  one  hand,  and  a  partial  de- 
struction of  the  hypophysis  on  the  other  hand  (hypophysis 
obesity),  should  both  cause  an  atrophy  of  the  genitalia,  no 


INTERNAL    SECRETIONS  115 

longer  seems  strange.  A  like  condition  exists  in  the  sphere 
of  the  thyroid,  where  Basedow's  disease  and  myxedema  may 
lead  to  an  inhibition  of  the  genital  function.  Because  of  the 
relation  between  hypophysis  and  ovary,  Thumin  advised  the 
treatment  of  acromegaly  with  ovarin,  and  advises  the  use 
of  hypophysis  extract  for  the  treatment  of  uterine  bleedings 
and  other  conditions  due  to  hyperfunction  of  the  ovaries.  The 
extract  of  the  posterior  lobe  acts  like  adrenalin,  strengthens 
and  slows  heart  activity,  increases  the  amount  of  urine,  and 
increases  the  contractility  of  smooth  muscle  fibers,  but  it  stimu- 
lates menstruation.     I  believe  the  anterior  lobe  does  not. 

"At  puberty  changes  occur  which,  if  the  hypophysis  is 
unstable,  may  so  alter  the  biochemical  processes  of  the  body 
that  they  border  on  the  pathologic.  The  rapid  increase  in 
stature  during  the  adolescent  period  probably  accounts  for  the 
occasional  spontaneous  glycosurias  of  this  period.  This  is 
probably  true  also  in  pregnancy  in  which  there  is  a  transient 
physiologic  hyperpituitarism." 

"In  pregnancy  hypertrophic  changes  occur  in  the  gland. 
Functional  alterations  occur  comparable  to  those  which  more 
obviously  affect  the  thyroid.  It  is  possible  that  hyperplasia  of 
the  hypophysis  may  account  for  some  symptoms  during  the  last 
weeks,  when  there  may  occur  fleeting  bitemporal  hemianopsia, 
hypertrophy  of  the  turbinates,  temporary  enlargement  of  the 
lips  and  nose,  with  thickening  of  the  tissues  of  the  hands  and 
feet,  the  frequent  glycosurias  of  pregnancy,  and  increase  in 
stature"  (Gushing). 

We  may  have  an  over-  or  underactivity  of  both  anterior 
and  posterior  lobes  or  of  either  one.  There  are  mixed  or  transi- 
tion cases  with  some  features  of  both  states.  This  may  be 
called  dyspituitarism.  There  may  have  been  an  overgrowth 
of  one  or  both  lobes,  followed  by  insufficiency  of  one  or  both 
lobes.  Other  individuals  suggest  by  undergrowth  and  adipos- 
ity, as  well  as  by  high  sugar  tolerance,  an  early  interference 
with  both  lobes.  Dystrophia  adiposo-genitalis  (Bartels)  is  due 
to  glandular  insufficiency.  All  cases  of  original  hyperpituitar- 
ism associated  with  tumor  may  end  in  hypopituitarism.    Many 


116  THE    ENDOCRINES 

cases  with  existing  hypopituitarism  show  traces  at  least  of  an 
early  tendency  to  hyperpituitarism.  Stages  of  pathologic  over- 
activity of  the  gland  tend  toward  a  final  stage  of  sluggishness 
in  the  way  of  secretion.  Symptoms  of  one  may  be  mixed  with 
symptoms  of  the  other.  Hence  the  value  of  the  term  dyspitui- 
tarism. 

Just  as  in  the  hyperthyroidism  there  are  periods  of  re- 
mission and  spontaneous  cure,  so  the  same  occurs  in  hypophysis 
affections. 

"It  is  probable  that  there  are  strains  which  run  through 
families  on  Mendelian  laws,  and  which  betray  the  existence 
of  ductless  gland  irregularities,  unrelated  to  any  postpartum 
influence.  This  includes  inherited  instability  of  the  hypophysis. 
There  are  authentic  instances  of  family  diabetes  of  both  kinds 
(mellitus,  insipidus).  Instability  of  the  hypophysis  may  cause 
in  various  members  of  different  generations  hyperfunction  in 
some,  hypofunction  in  others.  A  functional  glandular  instabil- 
ity may  make  various  members  of  the  family  susceptible  to 
various  alterations"  (Gushing). 

In  recent  years  hypophysis  diseases  have  been  treated  suc- 
cessfully by  operations.  Because  of  the  antagonism  between 
hypophysis  and  ovary,  Thumin  advises  the  treatment  of  acro- 
megaly with  ovarin,  and  advises  the  use  of  hypophysis  extract 
for  the  treatment  of  uterine  bleedings  and  other  conditions  due 
to  hyperfunction  of  the  ovaries.  The  extract  of  the  posterior 
lobe  acts  like  adrenalin,  strengthens  and  slows  heart  activity, 
increases  the  amount  of  urine,  and  increases  the  contractility 
of  smooth  muscle  fibers.  For  the  last  reason,  pituitrin  acts  well 
on  the  bladder  and  uterus.  It  has  a  styptic  action  in  various 
bleedings  in  the  non-pregnant  uterus  (?)  is  a  bladder  tonic, 
and  acts  well  in  some  cases  of  osteomalacia,  and  of  course  acts 
well  in  uterine  atony  in  labor. 

The  Adrenals 

Secretion  of  the  adrenal  glands  is  increased  in  great 
emotion.  The  adrenal  glands  are  subject  to  splanchnic  influ- 
ence.    Impulses  are  normally  sent  along  these  nerves  in  the 


INTERNAL    SECRETIONS  117 

natural  conditions  of  life  when  animals  become  greatly  ex- 
cited, as  in  fear,  rage,  or  pain. 

Since  the  adrenal  glands  are  intervated  by  the  sympa- 
thetic, and  since  the  adrenal  secretion  stimulates  the  same 
activities  that  are  stimulated  nervously  by  this  division,  it  is 
possible  that  disturbances  in  the  realm  of  the  sympathetic, 
although  initiated  by  nervous  discharge,  are  automatically 
augmented  and  prolonged  through  chemical  effects  of  the 
adrenal  secretion.     (Cannon.) 

There  is  every  possibility  that  these  glands  are  stimu- 
lated to  extra  secretion  at  these  times.  Injecting  adrenin  into 
the  blood  causes  liberation  of  sugar  from  the  liver  into  the 
blood  stream.  It  relaxes  the  smooth  muscle  of  the  bronchioles. 
It  acts  as  an  antidote  for  muscular  fatigue.  It  alters  the  dis- 
tribution of  the  blood  in  the  body,  driving  it  from  the  abdomi- 
nal viscera  into  the  heart,  lungs,  central  nervous  system,  and 
limbs.   It  possibly  renders  more  rapid  the  coagulation  of  blood. 

Glycosuria  may  be  promoted  by  pain,  in  animals,  and  in 
association  with  intense  pain,  in  human  beings ;  it  may  arise 
from  emotional  excitement.  In  other  words,  in  man  emotional 
excitement  produces  temporary  increase  of  blood  sugar.  Great 
muscular  effort  is  accompanied  by  heightened  arterial  pres- 
sure. Emotions  and  great  excitement  may  do  the  same.  Blood 
from  the  adrenal  veins  causes  relaxation  of  intestinal  muscles 
characteristic  of  adrenal  extract  or  adrenin.    (Cannon.) 

The  spleen,  the  kidneys,  and  the  intestines  suffer  a  con- 
siderable decrease  of  volume  when  adrenin  is  administered. 
Adrenin  causes  active  dilatation  of  the  vessels  in  muscles,  and 
constriction  of  cutaneous  vessels.  It  is  well  known,  however, 
that  adrenin  has  a  vaso-dilator,  not  a  vaso-constrictor,  action 
on  the  arteries  of  the  heart.  It  is  well  known  that  adrenin 
affects  the  vessels  of  the  brain  and  the  lungs  only  slightly,  if 
at  all. 

Adrenin  is  able  to  bring  about  a  rapid  recovery  of  normal 
irritability  of  muscle  after  the  irritability  has  been  much 
lessened  by  fatigue.  This  is  due  to  a  specific  action  of  adrenin 
and  not  wholly  to  its  influence  on  the  circulation.     Adrenin 


118  THE    ENDOCRINES 

opposes  the  effect  of  both  curare  and  fatigue.  What  rest  will 
do  after  an  hour  or  more  to  a  muscle  whose  original  ability  to 
respond  to  stimulation  has  been  largely  lost  by  continued  activ- 
ity through  a  long  period  adrenin  will  do  in  five  minutes  or 
less. 

The  liver  seems  to  furnish  continuously  to  the  blood  a 
factor  in  the  clotting  process  which  is  being  continuously  de- 
stroyed in  the  body.  It  is  not  unlikely  that  adrenin  makes  the 
blood  clot  more  rapidly  by  stimulating  the  liver  to  discharge 
this  factor  in  greater  abundance.  Sugar  and  adrenin,  which 
are  poured  into  the  blood  during  emotional  excitement,  render 
the  organism  more  efficient  in  the  physical  struggle  for  ex- 
istence. 

"Every  one  of  the  visceral  changes  that  have  been  noted, — 
the  cessation  of  processes  in  the  alimentary  canal  (thus  freeing 
the  energy  supplied  for  other  parts)  ;  the  shifting  of  blood 
from  the  abdominal  organs  whose  activities  are  deferrable  to 
the  organs  immediately  essential  to  muscular  exertion  (the 
lungs,  the  heart,  the  central  nervous  system)  ;  the  increased 
vigor  of  contraction  of  the  heart;  the  quick  abolition  of  the 
effect  of  muscular  fatigue;  the  mobilizing  of  energy-giving 
sugar  into  the  circulation — every  one  of  these  visceral  changes 
is  directly  serviceable  in  making  the  organism  more  effective 
in  the  violent  display  of  energy  which  fear  or  rage  or  pain 
may  involve."     (Cannon.) 

The  Ovaries,,  Their  Function  and  Relation  to  Normal 

AND  Pathologic  States 

Amenorrhea 

Knauer  transplanted  the  ovaries  of  rabbits  and  dogs  be- 
tween the  fasciae  of  the  abdominal  wall  and  into  the  mesome- 
trium,  being  careful  to  remove  absolutely  every  bit  of  ovarian 
structure.  In  the  abdomen  he  fastened  the  ovary  with  two 
sutures  between  folds  of  peritoneum,  the  ovaries  being  then 
nourished  through  endosmosis  or  through  plasmatic  circulation. 
New  vessels  grew  into  the  ovarian  tissue  and  furnished  its  sub- 
sequent support ;  this  change  began  as  early  as  the  fourth  day. 


INTERNAL    SECRETIONS  119 

Examination  at  various  periods  showed  that  a  small  part  of 
each  ovary  usually  degenerated,  and  new  connective  tissue  ap- 
peared in  the  place  of  the  lost  cells.  In  all  cases  in  which  a 
complete  degeneration  of  the  ovary  occurred,  atrophy  of  the 
breasts  and  of  the  genitalia  was  found.  The  muscle  of  the 
uterus  was  atrophied,  the  intermuscular  connective  tissue  was 
increased,  the  mucous  membrane  was  atrophied — changes  like 
those  which  occurred  after  double  castration.  Retention  of 
function  on  the  part  of  the  transplanted  ovaries  was  always 
evidenced  by  the  growth  of  follicles  in  a  normal  manner,  by  the 
ripening  of  the  follicles,  and  by  the  discharge  of  the  ova.  In  all 
such  cases  the  normal  character  of  the  breasts,  of  the  uterus, 
and  of  the  genitalia  was  preserved,  and  in  the  younger  animals 
all  these  organs  underwent  a  natural  development. 

Knauer's  results  proved  that  the  preservation  to  the  or- 
ganism of  functionating  ovaries  preserved  the  breasts,  the  geni- 
tal organs,  and  the  sexual  instinct.  This  result  occurs  through 
the  absorption  into  the  circulation  of  ovarian  secretion.  This 
internal  secretion  reaches  the  blood  through  the  lymph-chan- 
nels. The  trophic  function  which  the  ovary  exerts  upon  the 
body  stands  in  closest  relation  to  its  ability  to  form  ripe  ova. 
Ovarian  tissue  which  has  ceased  to  develop  ripe  ova  has  lost 
its  secretory  function. 

The  normal  human  ovary  produces  and  expels  ova  capable 
of  being  fecundated.  Ovulation,  as  a  rule,  occurs  from  eight 
to  ten  days  before  menstruation,  but  it  may  occur  at  earlier 
periods. 

The  ovaries  are  glands  with  an  outer  covering  of  germinal 
epithelium,  within  which  is  a  stroma  or  interstitial  tissue  con- 
taining thousands  of  follicles.  The  ovaries  thus  produce  an 
internal  secretion,  probably  two  different  varieties,  and,  in 
addition,  the  corpus  luteum,  which  develops  especially  during 
pregnancy,  produces  a  secretion  perhaps  of  a  different  char- 
acter, or  at  least  of  a  more  specific  nature  designed  to  stimulate 
the  thyroid  and  inhibit  the  posterior  pituitary  tendency  to 
bring  about  menstruation.  When  the  ovaries  begin  to  pro- 
duce the  accepted  adult  type  of  secretion,  the  result  is  made 


120  THE    ENDOCRINES 

apparent  by  the  onset  of  menstruation.  But  they  certainly 
are  functionating  before  this  period  of  puberty,  and  thus  they 
may  be  responsible  for  some  of  those  skeletal  differences  be- 
tween the  female  and  male  type,  such  as  the  difference  in  the 
form  of  the  pelvis.  The  ovaries  are  responsible  for  the  proper 
development  and  nutrition  of  the  external  and  internal  geni- 
talia. Their  main  protective  influence  is  exerted  upon  the 
uterus,  and  more  particularly  upon  its  lining,  the  endometrium. 
Infectious  diseases  occurring  in  infants  and  children,  which 
produce  changes  of  an  injurious  nature  in  the  ovaries  of  a 
permanent  character,  may  result  in  the  various  degrees  of 
under-development  of  the  genitalia.  These  include  measles, 
mumps,  scarlatina,  whooping-cough,  diphtheria,  tonsilitis, 
rheumatism,  chorea,  influenza,  etc.  These  diseases  of  child- 
hood and  adolescence  and  the  various  infectious  diseases  may 
affect  and  injure  not  only  the  endometrium,  the  tubes,  the 
ovaries,  but  likewise  any  one  or  more  of  the  endocrines  which 
are  trophically  related  to  the  development  of  these  genital 
structures.  Removal  of  the  ovaries  results  in  a  cessation  of 
menstruation,  and  the  absence  of  the  trophic  effect  of  their  se- 
cretion upon  the  uterus  is  evidenced  by  its  atrophy.  Experi- 
ments made  on  animals  have  proved  beyond  doubt  that  re- 
moval of  the  ovaries  in  the  newly  born  results  in  failure  of 
development  of  the  genitalia  and  of  the  breasts.  Removal  of 
the  ovaries  after  development  of  the  genitalia  and  the  breasts 
produces  regressive  changes  in  these  organs,  especially  in  the 
uterus.  If,  however,  these  ovaries  when  removed  from  their 
normal  site  are  transplanted  elsewhere  in  the  abdomen  or  in 
the  abdominal  wall,  and  establish  a  new  connection  in  these 
areas,  no  regressive  changes  occur  in  the  genitalia  and  in  the 
breasts.  It  is  a  fact,  then,  that  the  ovaries,  so  long  as  they  are 
"alive,"  no  matter  where  they  are  situated,  exert  this  trophic 
and  protective  influence  upon  the  uterus  and  genitalia,  through 
the  medium  of  the  circulation  and  this  by  virtue  of  an  Internal 
secretion  or  secretions. 

The  distinction  between  the  genitalia  of  the  two  sexes 
themselves  constitutes  the  "primary  sex  characteristics,"  but  a 


INTERNAL    SECRETIONS  121 

number  of  differences  which  are  not  connected  with  propaga- 
tion, but  which  are  characteristic  of  the  being  of  the  female, 
are  called  "secondary  sex  characteristics."  Among  these  are 
the  greater  tendency  to  fat  under  the  skin,  and  the  resulting 
rounding  of  the  body,  the  width  of  the  hips,  the  marked  de- 
velopment of  the  gluteal  region,  the  length  of  the  hair,  the 
absence  of  beard,  the  difference  in  the  larynx.  The  difference 
in  the  pelvis  is  very  marked.  There  is  a  slighter  development 
in  the  features  of  the  face,  especially  the  lower  jaw.  The  brain 
is  smaller.  Psychically,  even  as  children,  there  is  a  taste  for 
different  forms  of  play.  The  differences  are  already  apparent 
between  the  ages  of  eleven  and  fourteen  as  concerns  the  round- 
ing of  the  features,  the  increase  in  the  fat,  especially  in  the 
mammse,  in  the  gluteal  region,  on  the  thighs,  etc.  The  most 
important  of  the  secondary  sexual  characteristics  are  the  breasts 
(Novak). 

A  remarkable  development  of  the  mammary  glands  take 
place  at  puberty.  This  development  is  influenced  by  the  ovary. 
The  mammary  gland  assumes  the  part  of  a  secondary  charac- 
teristic of  the  female  sex,  attaining  to  complete  development 
under  the  influence  of  the  ripening  ovary.  (The  hypertrophy 
which  takes  place  in  pregnancy  is  not  due  to  the  ovary  alone 
but  to  the  trophoblast.)  The  real  function  of  the  mammary 
gland  is  developed  by  a  secretion  from  the  placenta,  which 
promotes  hyperplasia.  The  subsequent  suppression  of  this 
secretion  permits  the  onset  of  the  secretory  function  and  the 
posterior  pituitary  helps  the  development  of  this  function. 

The  interrelation  between  the  hypophysis  and  ovaries  is 
extremely  close.  In  the  ovary  there  are  four  glandular  ele- 
ments : 

(1)  The  follicles,  concerned  also  with  the  production  of 
ova. 

(2)  The  false  corpus  luteum  of  menstruation. 

(3)  The  corpus  luteum  of  pregnancy,  brought  into  ex- 
istence by  the  reaction  produced  by  placental  ferments. 

(4)  The  interstitial  cell-body. 

These  interstitial  cells  are  probably  related  to  the  acquire- 


122  THE    ENDOCRINES 

ment  of  the  secondary  sexual  characteristics.  "As  a  consequence 
of  preadolescent  castration  the  acquired  characteristics  of  sex 
fail  to  appear.  The  reproductive  functions  covered  by  the  fol- 
licles may  not  be  impaired,  even  though  complete  secondary 
sexual  characteristics  have  not  appeared.  The  element  of  the 
ovary  which  is  responsible  for  the  constitutional  physical 
changes  which  characterize  puberty  is  probably  the  interstitial 
cell  structure.  Cases  show  imperfectly  acquired  secondary 
sexual  characteristics  when  hypoph5^seal  lesions  antedate  puber- 
t}^,  and  a  resultant  amenorrhea  with  retrogressive  sexual 
changes  when  the  malady  develops  after  adolescence"  (Gush- 
ing). 

Hypersecretion  or  hyposecretion  of  the  hypophysis  cause 
other  changes  than  those  related  to  the  acquirement  of  adoles- 
cent characteristics.  Thus,  amenorrhea  ihay  be  an  early  symp- 
tom with  hypersecretion  or  hyposecretion  of  the  hypophysis. 

It  must  be  remembered  that  the  ripe  ovary  is  filled  with 
thousands  of  follicles  in  a  quiescent  state,  and  that  at  regular 
intervals  at  least  one  follicle  develops,  becomes  larger,  is  filled 
with  fluid,  approaches  the  surface  of  the  ovary,  breaks  through 
the  ovarian  covering,  and  throws  out  its  liquor  folliculi  and  the 
tiny  ovum  a  few  days  before  the  expected  menstruation,  and 
the  ruptured  follicle  develops  the  false  corpus  luteum.  It  may 
be  assumed  that  this  follicle,  with  its  contained  fluid  and  ovum, 
represents  either  an  added  amount  of  ovarian  secretion  or  a 
new  form  of  ovarian  secretion.  If  no  pregnancy  takes  place, 
the  corpus  luteum  becomes  smaller,  and  finally  ends  in  a  form 
of  scar  tissue.  If  pregnancy  does  occur,  it  develops  into  a 
progressively  growing  structure,  known  as  a  true  corpus  lu- 
teum. AVhy,  in  the  first  instance,  does  the  follicle  become  a 
scar  within  a  short  time,  and,  in  the  second  instance,  why  does 
it  remain  as  a  living  functionating  structure  for  several 
months  ?  As  the  corpus  luteum,  it  undoubtedly  has  a  function. 
The  explanation  which  we  wish  to  make  at  the  present  moment 
is  that  the  presence  of  the  fecundated  ovum  within  the  uterus 
and  the  placental  secretion  which  it  throws  into  maternal 
circulation  so  stimulates  the  ovary  (as  it  also  stimulates  other 


INTERNAL    SECRETIONS  123 

glands)  that  the  follicle  reacts  by  a  progressive  change,  and 
continues  as  a  living,  functionating  part  of  the  ovary  instead 
of  ending  its  follicle  function  by  becoming  a  healed  area.  The 
purpose  of  the  corpus  luteum  is  to  stimulate  the  thyroid 
(glandular)  and  inhibit  the  contractile  action  of  the  posterior 
pituitary  on  the  uterus. 

We  know  little  about  the  secretion  of  the  follicles,  yet  they 
probably  nourish  the  uterine  lining.  It  is  true  that  subsequent 
ovulation  in  pregnancy  is  interfered  with  by  the  corpus  luteum, 
so  that  pregnancy  may  not  be  interrupted  by  menstruation. 
The  integrity  of  the  uterus  depends  partly  on  the  secretory 
function  of  the  follicles,  and  they  produce  the  impulse  of  nutri- 
tion in  the  uterus,  which,  together  with  the  cyclic  phenomena 
of  premenstrual  and  menstrual  congestion  (interstitial  ovary) 
and  together  with  painless  contractions  between  menstruation 
(posterior  pituitary)  prevent  the  uterus  from  undergoing  atro- 
phy. How  much  the  hypophysis  may  have  to  do  with  these 
painless  contractions  is  no  longer  a  matter  of  conjecture.  The 
ovary,  especially  the  corpus  luteum,  produces  a  hormone,  which, 
in  association  with  the  cyclic  changes,  causes  and  stimulates 
decidual  cell  growth. 

The  secretion  of  the  interstitial  part  is  now  definitely 
known.  It  is  related  to  the  vagus  apparatus,  and  hence  the 
administration  of  lutein  rarely  corrects  the  annoyances  due  to 
climacteric  changes.  Biedl  thinks  that  the  interstitial  gland  con- 
trols the  cyclic  changes  in  the  genital  canal.  There  is  cer- 
tainly an  antagonistic  relationship  between  the  corpus  luteum 
and  the  follicles  on  the  one  hand  and  the  interstitial  gland 
on  the  other.  •  Alterations  in  other  glands  probably  do  not 
affect  these  two  elements  in  the  same  way  or  to  the  same 
degree.  Diseases  or  secretory  alterations  of  the  ovary,  as  yet 
unrecognized,  probably  involve  the  follicle  apparatus  and  the 
interstitial  gland  in  a  different  way  and  to  a  different  degree, 
so  that  there  may  be  hyperfunction,  or  hypofunction^  or  either, 
in  various  combinations. 

The  ovarian  secretion  is  responsible  for  menstruation.  It 
is  responsible  for  it  in  the  following  manner — it  has  a  constitu- 


124  THE    ENDOCRINES 

tional  action  on  various  mucous  and  serous  membranes  of  the 
body,  but  has  a  special  cumulative,  selective,  periodic,  conges- 
tive influence  upon  the  uterus,  whereby  the  uterus  becomes  filled 
with  blood,  the  capillaries  become  dilated,  the  endometrium  is 
stimulated  to  hyperplasia,  becoming  thicker  and  turgid,  the 
interstitial  cells  becoming  larger  and  hexagonal  in  form,  so 
that  the  uterus,  and  particularly  its  lining,  becomes  a  nest  ready 
for  any  ovum  which  may  settle  within  its  cavity.  This  is  a 
wonderful  provision  of  nature  to  furnish  a  thick,  hyperplastic, 
moss-like  lining,  on  which  and  in  which  the  fecundated  ovum 
may  embed  itself.  This  provision  is  wise  for  two  reasons — 
first,  it  gives  plenty  of  blood  to  serve  as  nutrition  for  the  ovum, 
and  second,  it  makes  a  thick  lining  into  which  the  egg  may 
settle.  It  must  be  mentioned,  at  this  point,  that  the  ovum  is, 
strictly  speaking,  a  parasite,  which,  by  the  very  nature  of  the 
growth  of  its  outer  layer  into  trophoblast  cells  and  chorionic 
villi,  has  a  decided  tendency  to  grow  deeply  through  the  uterine 
lining  into  the  uterine  well.  Here  comes  the  added  protective 
influence  of  the  corpus  luteum.  This  added  factor  further 
stimulates  the  uterine  lining,  making  it  a  still  thicker  mem- 
brane, and  in  this  way  furnishing  a  favorable  area  into  which 
the  egg  and  its  covering  cells  may  penetrate,  and,  at  the  same 
time,  by  the  very  thickness  of  this  membrane,  protecting  the 
uterine  wall  from  invasion. 

The  first  decidual  changes  in  the  uterus  are  produced  by 
the  ovaries.  It  is  true  that  removal  of  the  ovaries  in  preg- 
nancy, if  not  too  early,  causes  no  marked  change,  for.  In  spite 
of  double  castration,  pregnancy  takes  a  normal  course  and  so 
does  the  subsequent  milk  formation.  It  seems,  therefore,  that 
the  ovaries  trophically  take  care  of  the  uterus  and  of  the  en- 
dometrium, prepare  the  endometrium  for  the  nidation  of  the 
ovum,  and  then  give  way  to  other  secretions,  the  placenta  par- 
ticularly. One  ovary  contains  a  corpus  luteum,  and,  on 
theoretic  grounds.  It  would  seem  that  this  is  a  secretion  which 
should  continue  to  protect  the  uterus,  endometrium,  and  other 
body  tissues  against  the  local  and  systemic  invasion  of  the 
chorionic  villi  and  placenta.     This  may  Indeed  be  true,  and. 


INTERNAL    SECRETIONS  125 

after  double  castration  in  pregnancy,  either  this  ovarian  secre- 
tion or  corpus  luteum  secretion  remains  as  a  ferment,  and  thus 
continues  its  activity,  or  else  some  other  gland  structures 
(especially  the  placenta)  take  up  the  function  which  the  corpus 
luteum  previously  performs. 

•  During  pregnancy  changes  occur  in  various  of  the  gland 
structures  of  the  body.  A  decided  change  takes  place  in  the 
secretory  activity  of  the  hypophysis,  structural  changes  occur 
which  last  for  months,  so  that  the  gland  never  goes  back  to  its 
former  antepregnant  state.  Quite  frequently  during  pregnancy 
an  evident  stimulation  of  growth,  slightly  resembling  acro- 
megaly, brings  the  participation  of  th-e  anterior  hypophysis  to 
our  notice.  Since  the  introduction  of  pituitrin,  with  its  oft- 
times  magic  effect  in  stimulating  and  accentuating  labor  pains, 
we  have  proof  again  that  the  hypophysis  is  concerned  in  vari- 
ous ways  in  the  processes  of  pregnancy.  The  introduction  into 
the  body  economy  of  the  placental  element,  which  constitutes 
a  secretion,  has  its  effect  beyond  doubt  upon  various  gland 
structures  of  the  body,  and  it  is  quite  possible  that  this  secre- 
tion is  responsible  for  the  corpus  luteum  and  for  the  maximum 
decidual  reaction,  either  by  direct  influence  on  the  uterus  or 
indirectly  through  the  corpus  luteum. 

It  is  not  to  be  understood  that  only  the  thickness  of  the 
decidua  protects  this  lining  and  the  uterine  wall  from  penetra- 
tion by  the  villi ;  other  factors  enter  into  consideration ;  namely, 
certain  elements  or  enzymes  from  other  glands  in  the  blood 
and  in  the  decidua,  which  exert  a  delimiting  effect  on  those 
cells,  which  grow  into  the  decidua,  are  at  all  times  being  ab- 
ter  and  penetrating  power  of  these  trophoblast  cells  as  to  in 
this  way  also  protect  the  uterine  wall  from  their  too  deep 
growth.  It  must  not  be  overlooked  that  these  very  trophoblast 
cells,  which  grows  into  the  decidua,  are  at  all  times  being  ab- 
sorbed and  thrown  into  the  blood  current,  where  they  circu- 
late, become  dissolved,  and  constitute  what  we  have  called  the 
placental  secretion,  a  secretion  which  exerts  an  influence  on  the 
mother  from  the  very  first  moment  that  a  fecundated  ovum 
embeds  itself ;  in  fact,  the  only  satisfactory  explanation  for  the 


126  THE    ENDOCRINES 

cessation  of  menstruation  when  pregnancy  occurs  is  furnished 
by  making  use  of  the  fact  that  a  placental  secretion  exists. 
This  secretion,  when  absorbed,  plus  the  corpus  luteum,  acts  as 
an  antagonist  to  that  part  of  the  ovarian  secretion,  pituitary 
and  adrenals  which  causes  menstruation.  It  has  already  been 
stated  that  the  ovarian  secretion  produces  the  congestion  and 
hyperemia  in  the  premenstrual  few  days.  This  congestion  and 
hyperemia  rises  to  such  a  high  pitch  that  diapedesis  and  rhexis 
occur  in  the  capillaries  of  the  endometrium,  which  relieves  the 
tension  in  that  tissue,  the  consequent  loss  of  blood  constituting 
the  phase  known  as  menstruation.  It  can  be  readily  under- 
stood that  an  overstimulation  on  the  part  of  the  ovarian  secre- 
tion may  be  responsible  in  this  way  for  a  too  profuse  flow  of 
blood.  The  character  of  the  blood  itself,  or  a  lack  of  a  proper 
coagulating  ferment,  or  an  abnormal  character  of  the  capil- 
laries, may  be  responsible  for  a  too  profuse  flow  of  blood.  An 
abnormal  type  of  endometrium,  such  as  is  commonly  called 
''fungoid,"  or  the  existence  of  a  diffuse  or  localized  polypoid 
form  of  mucous  membrane,  may  result  from  overstimulation 
by  ovarian  hormones  or  by  the  posterior  pituitary  or  by  the 
adrenals,  and  may  be  readily  responsible  for  an  excessive  flow 
of  blood.  A  uterus  which  does  not  contract  well  and  which, 
because  of  rhythmic  repeated  contractions  of  insufficiently 
effectual  power,  does  not  hasten  the  approach  of  the  relative 
anemia  of  the  postmenstrual  period,  will  naturally  be  respon- 
sible for  a  too  excessive  flow  or  a  too  protracted  flow  of  blood. 
In  other  words,  if  a  uterus  is  normal,  if  its  lining  is  normal, 
and  if  the  blood  is  normal,  such  a  uterus  is  able  to  resist  the 
hyperemic  congestive  influence  of  the  ovarian  secretion  for  a 
certain  period  only.  That  period  follows  in  the  human  being, 
as  a  rule,  the  type  of  twenty-eight  days.  If  this  secretion  is 
too  powerful  in  its  effect,  or  if  the  blood  or  the  lining  of  the 
uterus  are  abnormal,  then  the  capillaries  cannot  resist  this  con- 
gestive influence  for  the  period  of  twenty-eight  days,  and  men- 
struation occurs  too  early  or  else  too  long.  On  the  other 
hand,  the  ovarian  secretion,  or  the  other  gland  secretions,  may 
be  of  such  a  diminished  energy  or  power  that  it  is  unable  in  an 


INTERNAL    SECRETIONS  127 

interval  of  only  twenty-eight  days  to  produce  sufficient  tension 
or  change  in  the  capillaries  as  to  have  them  break  and  allow 
a  flow  of  blood ;  or  the  endometrium  or  the  capillaries  may  be 
so  constituted  or  altered  that  they  resist  this  power  of  the 
ovaries  and  other  glands,  and  for  either  of  these  reasons  the 
menstrual  interval  is  prolonged  to  five  weeks,  six  weeks,  two 
months,   or  ofttimes  longer,   regularly  or  irregularly.     This 
does  not  of  necessity  affect  the  power  of  the  ovary  to  produce 
ova  capable  of  fecundation.     When  the  ovarian  enzyme,  or 
enzymes,  are  producing  this  congestion  in  uterus,  and  bringing 
on  such  a  turgid  condition  of  the  endometrium  as  to  presup- 
pose the  relief  of  this  state  by  the  outflow  of  blood,  if  before 
this  time  a  fecundated  embedded  ovum  throws  its  own  par- 
ticular enzyme  into  the  circulation,  it  either  nullifies  this  par- 
ticular phase  of  the  ovarian,  pituitary  and  adrenal  secretions' 
activities  or  else  it  locally,  or  through  the  blood,  affects  or 
alters  the  capillaries,  and  by  either  of  these  two  processes  the 
outflow  of  blood  is  inhibited.  It  may  be,  then,  taken  for  granted 
that  during  the  succeeding  months  of  pregnancy  it  is  the  par- 
ticular function  of  the  ovarian  secretion,  with  the  newly  added 
power  of  the  corpus  luteum,  to  trophically  nourish  and  stimu- 
late the  uterine  lining  and  the  uterine  wall,  and  to  thus  pro- 
tect it  against  the  local  activities  of  the  ovum.     We  have  a 
right  to  suppose  that  the  ovarian  secretion,  together  with  the 
added  secretion  of  the  corpus  luteum,  has  a  constitutional  in- 
fluence whereby  its  enzyme  power  is  exerted  to  influence  that 
secretion  which  the  ovum,  through  the  growth  of  its  outer 
layers,  is  continually  throwing  into  the  body.     In  other  words, 
we  may  with  reason  express  the  conviction  that  the  ovaries  are 
among  the  glands  which  aid  the  mother  in  her  fight  against 
the  local  and  constitutional  activities  of  the  parasitic  ovum  and 
its  placental  secretion. 

We  know  that  the  development  of  the  genital  glands  is 
influenced  by  a  large  number  of  internal  secretory  organs. 
Early  and  exceptional  development  of  the  body  and  genital 
glands  may  be  the  result  of  tumors  occurring  in  the  supra- 
renals,  in  the  pituitary  glands,  or  the  pineal  gland       Other 


328  THE    ENDOCRINES 

hypophyseal  affections,  except  overactivity  of  the  posterior 
lobe,  tend,  as  a  general  rule,  to  genital  atrophy. 

The  effect  of  late  genital  maturity,  like  that  of  genital 
hypoplasia,  is  to  increase  the  height,  especially  the  length  of 
the  legs,  while  early  genital  maturity  causes  premature  clos- 
ing of  the  epiphyses  and  is  associated  with  short  legs.  The  re- 
lationship between  the  ovaries  and  those  other  secretory  organs 
which  influence  the  growth  of  bone  is  remarkable.  Castration 
is  followed  by  changes  in  the  thyroid,  thymus,  adrenals,  hypo- 
physis. RemoA^al  of  the  ovaries  causes  an  increase  of  the  hy- 
pophysis. Certain  changes  in  pregnancy  resembling  acrome- 
galy are  due  to  primary  hypof unction  of  the  glandular  ovary 
and  secondary  hyperfunction  of  the  anterior  hypophysis,  since, 
during  pregnancy,  normal  glandular  ovarian  activity  is  in  a 
way  inhibited.  The  menopause  is  associated  with  regressive 
changes  in  the  internal  secretory  organs,  especially  the  thy- 
roid, but  overactivity  of  the  posterior  pituitary  may  persist. 

After  castration  metabolism  is  much  reduced.  The  dimin- 
ished metabolism  may  be  raised  by  ovarian  extract.  The  in- 
crease in  metabolism  is  due  to  the  changes  in  substances  which 
do  hot  contain  nitrogen.  There  is  a  close  relationship  between 
the  ovaries  and  the  suprarenal  medulla  and  cortex.  The  prin- 
ciple role  in  osteomalacia,  too,  is  played  by  the  ovaries.  The 
ovaries  have  always  been  considered  as  a  factor  in  chlorosis, 
either  through  hypo  function  or  malfunction.  Wallart  thinks 
there  is  a  relationship  between  the  interstitial  ovarian  secretion 
and  the  formation  of  the  blood. 

Castration  never  produces  the  positive  characteristics  of 
the  opposite  sex,  but  results  in  a  certain  fixation  of  an  infantile 
type.  Early  castration  is  followed  by  excessive  longitudinal 
growth,  a  lack  of  proportion  between  the  length  of  the  trunk 
and  that  of  the  extremities. 

It  seems  that  after  castration  the  body  length  is  greater. 
The  sella  turcica  is  then  increased  as  an  expression  of  the 
enlargement  of  the  hypophysis.  Removal  of  the  ovaries  causes 
a  great  atrophy  of  the  uterus,  has  a  little  effect  on  the  vagina, 
and  almost  none  on  the  external  genitalia,   since  these  are 


INTERNAL    SECRETIONS  129 

trophically  supported  by  the  posterior  pituitary.  In  individuals 
castrated  during  the  early  years  the  instinct  of  sexual  desire 
does  not  exist  unless  there  has  been  a  preceding  somatic  psy- 
chic-sexual puberty.  Has  there  once  been  an  awakening  of  the 
sexual  desire,  or  an  actual  experience  of  it,  then  the  memory 
pictures  obtained  thereby  (the  so-called  libido  centralis)  work 
against  the  disappearance  of  the  "Geshlechtstrieb"  after  castra- 
tion. For  this  reason  the  majority  of  cases  of  castration  find 
little  difference  in  libido.  Libido  is  more  dependent  on  pos- 
terior pituitary  than  on  the  ovaries. 

Puberty  is  a  critical  period  for  the  growing  girl.  The 
ovary  begins  to  manifest  the  power  which  it  is  to  exert  for 
many  years.  It  exerts  its  function  to  a  heightened  degree  lo- 
cally in  the  pelvis ;  it  exerts  its  function  probably  on  psychic 
channels ;  and  it,  in  all  probability,  so  stimulates  other  glandu- 
lar functions  that  the  organism  of  the  girl  adapts  itself  to 
these  new  influences  with  variations,  from  that  of  a  simple 
adjustment,  up  through  the  various  degrees  of  temporary  mal- 
adjustment to  the  highest  degree  of  temporar}'  or  protracted 
maladjustment.  In  this  connection,  we  must  pay  attention 
most  particularly  to  the  elements  of  the  thyroid  and  posterior 
pituitary  secretion.  AMien  the  ovary  begins  to  assume  its  full 
active  position  in  the  economy  of  the  growing  girl,  changes  of 
a  marked  nature  occur  with  a  certain  degree  of  twenty-eight 
day  regularity.  Wq  must  credit  the  impulse  of  these  changes 
to  the  secretion  produced  by  the  ovaries.  By  cumulative  ac- 
tion, a  gradual  congestion  and  hyperemia  and  a  stimulation  or 
irritation  in  produced  in  many  portions  of  the  body  at  intervals 
of  twenty-eight  days.  Before  and  during  menstruation  the 
vocal  chords  become  hyperemic;  the  same  hyperemia  occurs 
in  the  mucous  membrane  of  the  stomach  and  intestines  and  in 
the  mucous  membrane  of  the  nose.  There  is  a  tendency  to 
irritability  in  the  central  nervous  system,  the  breasts  become 
full  and  sensitive,  there  is  a  feeling  of  weight  in  the  pelvis. 
These  symptoms,  and  other  annoyances  of  a  still  greater  de- 
gree, in  many  instances  precede  the  onset  of  menstruation, 
and  represent  the  highest  point  of  the  premenstrual  wave,  the 


130  THE    ENDOCRINES 

symptoms  persisting  more  or  less  during  menstruation  and 
then  gradually  ebbing  away.  Some  patients  are  almost  un- 
aware, so  far  as  constitutional  manifestations  are  concerned, 
of  the  onset  of  menstruation,  while  others  can  foretell  this 
period  by  one  or  more  of  these  prodromal  symptoms.  So  far 
as  the  irritability  of  the  nervous  system  is  concerned,  the  de- 
gree to  which  the  individual  reacts  to  the  premenstrual  and 
menstrual  stimulus  is  an  index  of  the  stability  of  the  endocrine 
system.  It  is  not  so  much  the  fact  that  ovarian  secretion  of 
different  strengths  effects  these  different  degrees  of  irritability, 
etc.,  as  it  is  that  organisms  and  nervous  systems  of  different 
grades  of  resistance  react  differently  to  this  premenstrual 
change  in  all  the  endocrines.  A  question  of  importance  con- 
cerns the  probability  of  other  secretions  than  the  ovarian,  such 
as  posterior  pituitary,  adrenal  medulla,  thyroid,  as  factors  in 
the  production  of  some  of  these  annoyances. 

Many  girls  enter  into  the  menstrual  phase,  irregularly 
or  regularly,  with  few,  if  any,  constitutional  annoyances.  Some 
go  on  in  this  placid  way  during  a  greater  or  the  entire  portion 
of  their  lives,  unless  some  intercurrent  condition  alters  this 
smooth  progress.  Others  at  some  subsequent  period  acquire 
varying  degrees  of  constitutional  phenomena  in  association 
with  the  premenstrual  and  menstrual  cyclic  phases.  In  some 
instances  puberty  has  associated  with  it  symptoms  of  an  annoy- 
ing character,  which  may  disappear  after  a  certain  period  of 
time,  or  which  may  persist  or  grow  worse  at  a  later  period. 
At  puberty  there  is  a  tendency  to  cardiac  irregularity,  short- 
ness of  breath,  and  symptoms  of  a  nervous  nature,  which  may 
be  due  to  the  inability  of  the  system  to  adjust  itself  calmly  to 
the  ovarian  secretion,  or  it  may  be  due  to  the  fact  that  the 
OA^aries,  which  are  to  be  viewed  as  closely  related  to  the  thyroid, 
pituitary  and  adrenal  glands,  so  stimulate  the  glandular  thy- 
roid and  the  adrenal  medulla  and  the  posterior  pituitary  that 
these  act  irregularly,  often  with  too  great  force,  and,  there- 
fore, though  in  varying  degrees,  the  individual  Is  really  suf- 
fering from  h5^perthyroidism,  a  hyperactivity  of  the  adrenal 
medulla  or  hyperactivity  of  the  posterior  pituitary.     In  some 


INTERNAL    SECRETIONS  131 

cases  the  ovarian  secretion  and  corpus  luteiim  are  constantly 
stimulating  the  thyroid ;  in  other  instances,  it  may  do  so  at  ir- 
regular intervals.  It  may  be  seen  from  these  statements  that 
either  secretion  may  stimulate  the  other  gland,  or  may  influence 
the  other  by  its  own  superior  power.  In  other  words,  the 
ovaries  may  secrete  too  little.  If  the  thyroid  secretion  does  not 
diminish  in  equal  ratio,  then  there  is,  relatively  speaking,  too 
much  thyroid  in  the  body.  There  may,  on  the  other  hand, 
be  too  much  thyroid  secreted,  and  this  may  so  antagonize  the 
secretion  of  the  ovaries  that  their  function  is  not  properly  car- 
ried out.  The  ovaries  may  be  secreting  too  much,  and  this  ex- 
cess of  secretion  may  either  overstimulate  the  thyroid  gland  or 
may  antagonize,  and,  to  a  certain  degree,  inhibit  the  thyroid 
gland's  function.  In  some  instances  there  may  be  too  much 
secreted  by  both  thyroid  and  ovary;  in  other  instances  they 
may  each  be  secreting  entirely  too  little.  In  this  way  there 
may  be  produced  a  variety  of  s}'mptoms,  either  before  or  dur- 
ing menstruation,  or  at  certain  regular  or  irregular  inter^-als, 
or  more  or  less  continuously.  What  part  the  hypophysis  and 
adrenals  may  play  in  the  production  of  these  relations,  or  what 
part  they  may  play  in  association  with  ovarian  and  thyroid 
secretions,  is  quite  apparent.  It  is  of  interest  to  recall  a  few^ 
facts  concerning  the  thyroid  gland.  The  thyroid  gland  has  an 
important  function  in  women,  and  it  is  abnormally  altered  in 
them  much  more  frequently  than  in  men.  ^lyxedema  and 
Basedow's  disease  are  far  more  frequent  in  women  than  in 
men.  The  thyroid  gland  seems  to  swell  before  menstruation; 
during  pregnancy,  before  and  during  labor,  though  the  stimu- 
lation produced  by  the  corpus  luteum  and  the  trophoblast.  The 
frequent  tendency  to  irritability  of  the  ner\^ous  system  during 
these  periods  is  to  be  traced  to  the  relation  between  the  ovarian,, 
pituitary,  adrenal  and  thyroid  secretions,  which  practically  at 
these  times  constitutes  a  hyperthyroidism,  or  hyperadrenalism, 
or  hyperpituitarism.  On  the  other  hand,  there  are  actual  periods 
of  hypothyroidism,  hypoadrenalism,  hypopituitarism,  asso- 
ciated with  which  there  may  be  a  coincident  diminution  of 
the  ovarian  function,  or  the  ovarian  function  may  be  actually 


132  THE    ENDOCRINES 

or  relatively  increased,  and  it  is  possible  that  in  certain  cases 
actual  hyperfunction  on  the  part  of  the  ovaries  may  be  respon- 
sible for  a  relative  hypofunction  of  the  thyroid.  It  may  be 
readily  seen  that  this  play  of  the  secretions,  altered  as  their 
relation  must  necessarily  be  during  the  various  phases  through 
which  womankind  goes,  renders  instability  of  the  nervous  sys- 
tem quite  frequent.  It  is  this  condition  which  aids  materially 
in  making  womankind  the  weaker  sex,  and  not  until  the  meno- 
pause comes  on,  and  not  until  the  ovarian  secretion  and  the 
thyroid  and  other  endocrines  finally  assume  a  quiescent  and  not 
constantly  changing  relationship,  do  thousands  of  women  find 
that  peace  of  bodily,  nervous,  and  mental  function  to  which 
we  give  the  name  of  good  health.  When,  to  these  various 
alterations,  there  is  added  the  function  of  the  breasts  and  the 
influence  which  lactation  or  the  absence  of  lactation  exert  we 
have  another  factor  which  increases  the  instability  of  which 
we  have  made  mention. 

Development  of  the  breasts  depends  to  a  great  extent 
on  the  trophic  stimulation  of  the  ovaries  and  the  posterior 
pituitary.  They  develop  markedly  before  puberty.  In  the 
climacterium  there  is  a  progressive  atrophy  of  the  mammae. 
The  relation  between  the  two,  mamma  and  genitalia,  is  not 
through  nerve  channels  only.  Hypoplasia  of  the  mammae  oc- 
curs in  young  animals  after  castration  and  may  be  avoided  by 
ovarian  transplantation.  The  pregnancy  changes  in  the  mam- 
mae are  due  to  some  new  internal  secretion.  The  development 
of  the  breasts  before  puberty,  their  rapid  growth  at  that  period, 
their  swelling  before  menstruation,  their  atrophy  at  the  meno- 
pause, are  dependent  primarily  on  the  secretion  of  the  ovaries. 
What  new  secretion  prompt  the  marked  hypertrophy  during 
pregnancy  and  the  secretion  of  milk  after  labor?  Both  these 
alterations  take  place  even  if  the  ovaries  have  been  removed 
early  In  pregnancy.  According  to  Halban,  the  placenta  dur- 
ing pregnancy  assumes  some  of  the  functions  of  the  glandular 
ovary,  the  activity  of  the  latter  being  supposedly  inhibited  dur- 
ing this  state.  After  labor,  when  the  placental  secretion  is  no 
longer  to  be  considered,  a  puerperal  involution  takes  place  in 


INTERNAL    SECRETIONS  133 

the  mammae  and  milk  is  secreted.  It  has  often  been  noticed 
that  the  secretion  in  the  breasts  during  pregnancy  changes  to 
milk  when  the  fetus  dies;  hence,  cessation  of  function  on  the 
part  of  the  placenta  seems  to  be  necessary  to  starting  the  secre- 
tion of  milk.  On  the  other  hand,  injection  of  placental  extract 
increases  the  milk  secretion  in  nursing  animals  and  rouses  a 
secretion  which  has  nearly  stopped.  According  to  Halban, 
ovarian  secretion  and  the  placental  secretion  have  analogous 
functions.  From  the  theoretic  standpoint,  it  always  seemed 
to  me  that  the  interstitial  ovary  and  placenta  are  antagonistic, 
and  that  the  ovary  is  one  of  the  glands  which  protects  the 
uterus  from  too  deep  inroads  on  the  part  of  the  trophoblast 
cells.  At  any  rate,  the  ovaries  and  other  endocrines,  when 
they  again  come  into  function  after  labor,  are  able  to  produce 
in  the  breasts  the  secretion  of  milk.  In  other  words,  the 
ovaries  take  trophic  care  of  the  breasts;  when  placental  se- 
cretion is  added  to  the  circulation  some  preparatory  change 
takes  place  in  the  mammae  which  is  essential  to  milk  forma- 
tion. Milk  formation  then  takes  place  only  when  this  placen- 
tal secretion  is  removed  as  an  active  factor.  Then,  it  seems 
the  ovaries,  posterior  pituitary  and  the  other  endocrines  aid 
in  establishing  the  flow  of  milk,  though  this  occurs  even  when 
the  ovaries  have  been  removed.  What  relation  the  thyroid 
bears  to  milk  formation  is  not  known.  We  do,  from  practical 
experience,  realize  that  small  doses  of  thyroid  extract  or  of 
suprarenal  extract  stimulate  the  breasts  to  increased  function, 
but  this  is  probably  only  another  evidence  of  the  great  im- 
portance of  the  thyroid  and  other  glands  in  the  metabolism  of 
the  body. 

In  climacteric  uterine  atrophy  there  are  usually  anatomic 
or  clinical  evidences  of  a  hypofunction  of  the  ovaries.  The 
absence  of  molimina  menstrualia  speak  for  like  atrophic  pro- 
cesses In  the  ovaries  and  uterus.  Senile  involution  and  lacta- 
tion atrophy  are  In  a  degree  physiologic.  Thorn  believes  that 
stimuli  which  pass  out  from  the  mammae  are  the  cause  of 
uterine  contractions  which  result  in  lactation  atrophy.  Lacta- 
tion atrophy  Is  probably  a  result  of  a  temporary  cessation  of 


134  THE    EXDOCRIXES 

function  on  the  part  of  the  ovaries,  with  contraction  of  the 
uterus  produced  by  mammary  secretion,  or  is  due  to  a  diver- 
sion of  ovarian  trophic  influence  to  the  breasts,  in  this  way 
depriving  the  uterus  of  its  regular  stimulation.  In  lactation 
atrophy  vasomotor  annoyances,  such  as  seen  after  castration, 
are  not  evident.  Some  ovarian  activity  perhaps  persists.  That, 
part  of  the  ovary  which  prevents  flushes  is  intact,  though  there 
is  a  disturbance  of  the  follicle  secretion  resulting,  as  a  rule,  in 
failure  of  ovulation  when  amenorrhoea  exists. 


CHAPTER  V 
THE  ENDOCRINES  IN  GYNECOLOGY 

First,  a  few  words  about  the  physiology  of  the  normal 
functions.  Menstruation  is  dependent  upon  the  normal  de- 
velopment of  the  genitalia  and  the  normal  trophic  control 
of  these  structures.  The  glands  of  greatest  importance  are 
the  ovary,  the  thyroid,  the  pituitary  and  the  adrenals.  Every 
menstruation  is  a  crisis  in  which  the  ovary,  thyroid  and 
pituitary  especially  participate.  Menstruation  is  preceded  by 
■premenstrual  phenomena  varying  in  intensity  and  degree  ac- 
cording to  the  actions  and  interactions  of  these  glands.  Ex- 
cessive activity  of  the  pituitary  is  characterized  by  the  same 
uterine  contractions  and  cervical  changes  as  occur  in  labor. 
Menstruation  is  a  miniature  labor,  labor  is  a  magnified  men- 
struation. 

Physiological  amenorrhea  occurs  during  pregnancy  and 
at  the  climacterium,  and  during  lactation.  The  amenorrhea 
of  pregnancy  is  due  to  the  inhibiting  influence  of  the  tropho- 
blast,  chorion  and  subsequent  placenta.  The  amenorrhea  of 
lactation  is  due  to  the  inhibiting  influence  of  mammary  se- 
cretion acting  on  uterus,  ovaries  and  related  glands. 

The  Inhibiting  influence  of  the  mammary  secretion  is  by 
no  means  absolute,  for  many  patients  either  menstruate  dur- 
ing lactation  or  after  the  first  few  months  of  lactation  or  con- 
ception may  take  place  during  the  amenorrhea.  The  amenor- 
rhea of  pregnancy  is  generally  absolute.  But  during  this 
whole  period  there  is  a  contest  between  the  glands  producing 
menstruation  and  the  inhibiting  secretion  from  the  ovum. 
Many  patients  have  menstrual  molimina  during  some  or  all 
the  months  of  gestation ;  some  have  varying  degrees  of  spot- 
ting or  staining  at  what  would  have  been  menstrual  periods; 
others  menstruate  or  bleed  profusely,  the  uterus  contracts  and 
the  ovum  is  expelled.  In  other  words,  the  secretion  of  the 
ovum  was  unable  to  inhibit  the  combined  activity  of  the  ovary, 
thyroid  and  pituitary  for  the  normal  period  of  two  hundred 

135 


136  THE   ENDOCRINES 

and  sixty  odd  days.  This  then  is  the  explanation  in  the 
greatest  proportion  of  cases  of  habitual  miscarriage. 

The  thymus  gland  is  supposed  to  regress  and  by  its  re- 
gression and  the  removal  of  its  inhibitory  influence,  de- 
velopment of  the  sex  organs  is  allowed  to  proceed.  There- 
fore an  early  or  late  regression  or  a  failure  to  regress  is  sup- 
posed to  influence  the  period  when  menstruation  develops 
and  the  character  of  the  menstruation. 

Tumors  of  the  hypophysis,  the  pineal  gland  and  the 
suprarenal  gland  have  resulted  in  many  instances  in  an  ex- 
ceedingly early  and  notable  development  of  the  genital  struc- 
tures. This  precocious  sex  development,  however,  is  not  asso- 
ciated with  a  correspondingly  early  and  precocious  develop- 
ment of  the  brain  and  mental  maturity. 

With  this  preliminary  sketch  it  may  be  readily  recognized 
how  the  activities  of  the  sex  organs  of  the  female  are  in- 
fluenced in  the  way  of  stimulation  and  inhibition  by  the  other 
endocrine  structures  and  it  must  be  apparent  that  primary 
activities  of  these  sex  organs  may  correspondingly  affect  the 
associated  endocrines. 

Many  points  of  interest  are  elucidated  in  history  taking; 
the  age  at  which  menstruation  was  first  established,  its  regu- 
larity, duration  and  other  important  data.  Severe  premen- 
strual phenomena  consisting  of  physical  and  psychic  deviations 
point  to  an  exaggerated  susceptibility  on  the  part  of  the  patient 
and  to  an  instability  in  the  endocrine  chain.  Early  appear- 
ance of  the  menopause,  especially  when  it  is  a  familial  tendency, 
speaks  for  a  lessened  energy  of  the  endocrine  chain  in  its 
relation  to  menstruation.  Women  whose  menstruation  occurs 
say  at  thirty-five  day  intervals  are  in  need  of  endocrine  stimu- 
lation. They  are  more  likely  to  begin  labor  at  a  date  later 
than  estimated.  Women  with  hypoplasia  of  the  uterus  and 
those  who  become  pregnant  after  endocrine  therapy  often  have 
a  long  and  tedious  labor.  Women  who  have  repeated  mis- 
carriages are  probably  hyperpituitary  and  when  they  finally 
do  carry  a  viable  child  may  not  go  to  full  term.  Some  women 
are  delivered  in  successive  pregnancies  say  three  weeks  before 


THE   ENDOCRINES    IN    GYNECOLOGY  137 

the  expected  date  each  time.  The  longer  the  period  of  amenor- 
rhea during  lactation  the  less  assertive  are  the  endocrines  of 
that  individual  in  regard  to  menstruation.  It  must  be  stated 
that,  because  the  endocrines  are  normal  in  their  co-operation  in 
relation  to  menstruation,  it  does  not  necessarily  prove  their  sta- 
bility as  related  to  other  physical  and  mental  functions,  but  it 
certainly  points  in  that  direction. 

We  may  on  pelvic  examination  likewise  discover  condi- 
tions due  to  the  endocrines.  But  the  outward  physical  mani- 
festations of  over-  or  under-activity  may  be  relatively  absent, 
particularly  if  the  changes  in  the  gland  relationship  have  been 
recent.  We  know  that  gland  abnormality  may  be  evidenced  in 
one  individual  by  predominantly  physical  signs,  in  another  pre- 
dominantly evidenced  by  altered  visceral  function  or  meta- 
bolism. In  another  the  effect  is  predominantly  on  the  mental 
reactions  and  psyche.  In  extreme  cases  there  are  various 
grades  of  combinations  of  all  three. 

The  uterus  may  develop  subnormally  with  a  resulting 
hypoplasia  and  subnormal  menstruation.  The  uterus  may 
have  developed  normally  and  only  subsequently  may  its  size 
and  the  degree  of  menstruation  diminish.  Here  is  a  distinction 
between  hypoplasia  and  atrophy.  Development  may  be  delayed 
and  uterine  hypoplasia  may  be  only  an  intermediary  stage 
leading  to  subsequent  normality.  Body  growth  may  be  back- 
ward and  yet  subsequent  endocrine  autostimulation  may  pro- 
duce a  normal  individual.  Hypophysis  overactivity  may  de- 
velop a  normal  giant  or  a  real  giant.  Late  overactivity  of  the 
hypophysis  produces  the  acromegalic  individual.  Late  hypo- 
thyroidism is  a  different  picture  from  the  infantile  or  child- 
hood type. 

Varying  degrees  in  the  intensity  of  the  gland  changes, 
as  well  as  in  the  location  and  extent,  furnish  gradations  in 
symptoms.  Consider,  for  example,  hyperthyroidism.  We  may 
have  a  typical  Graves'  or  Basedow's  disease  with  exophthalmos, 
goitre,  tachycardia,  tremor  and  associated  gastric  and  nervous 
annoyances.  There  may  be  varying  degrees  of  severity  and 
toxicity;    there    may   be   marked    involvement    of   associated 


138  THE    ENDOCRINES 

glands.  We  may,  on  the  other  hand,  have  simply  a  paroxysmal 
or  continuous  tachycardia,  or  only  the  nervous  manifestations, 
or  menstrual  anomalies  may  first  dominate  the  picture  in  the 
latent  cases.  Therefore,  as  regards  changes  in  the  endocrines, 
we  may  have  innumerable  variations  in  the  location,  intensity 
and  extent  of  the  symptoms.  Just  as  we  have  varying  degrees 
of  pulmonary  tuberculosis,  we  may  have,  I  believe,  variations 
in  the  involvement  of  the  suprarenal  glands,  for  instance,  and 
it  would  be  only  following  this  analogy  to  say  that  early  and 
unrecognized  involvement  of  the  suprarenals  may  go  on  to 
healing,  and  the  cause  of  the  associated  asthenia,  with  or 
without  slight  skin  manifestations,  may  be  unrecognized. 

With  a  given  etiology  we  may  have  several  of  the  en- 
docrine glands  injuriously  affected.  These  may  result  in  as- 
thenia after  labor,  after  prolonged  lactation,  after  infections, 
after  influenza  and  these  should  be  diagnosed  as  cases  of  pluri- 
glandular endocrine  exhaustion.  We  may  in  other  cases  have 
one  gland  singled  out  for  marked  injury,  as  for  instance  the 
adrenals  or  the  thyroid.  On  the  other  hand,  the  test  to  which 
any  one  or  more  of  the  glands  have  been  subjected  by  physio- 
logical or  pathological  conditions  may  result  in  an  increased 
secretory  activity  of  one  or  more  members  of  the  chain,  as  in 
thyroiditis.  The  best  instance  of  this  is  to  be  found  during 
pregnancy  and  after  labor  when  many  patients  give  evidence 
of  improved  health,  bony  growth  and  general  systemic  exhil- 
aration. This  is  merely  a  continuation  of  the  increased  gland- 
ular activity  aroused  in  the  endocrine  chain  by  the  growing 
ovum. 

Based  on  the  belief  that  the  ductless  glands  preside  over 
the  development  of  the  inherited  body  and  mind,  controlling 
and  regulating  many  of  their  functions  through  all  the  years 
of  life,  the  theory  of  treatment  by  endocrlnes  follows  two 
plans:  1,  give  those  extracts  of  which  the  body  is  producing 
too  little;  2,  if  the  body  is  producing  too  much  of  any  one 
extract,  attempt  to  counteract  this  overactivity  by  giving  other 
hormones  which  diminish,  oppose  or  inhibit  this  oversecretion. 


THE    ENDOCRINES    IN    GYNECOLOGY  139 

To  go  about  this  procedure  rationally  we  must  have  a 
knowledge  of  the  physiological  action  of  the  various  glands 
and  their  probable  hormones ;  second,  w- e  must  note  the  changes 
produced  by  overactivity  or  underactivity  of  the  glands  as  evi- 
denced by  definite  physical  and  other  signs  essential  to  diag- 
nosis; third,  by  the  administration  of  gland  extracts  in  a 
therapeutic  manner  we  have  the  opportunity  of  verifying  these 
physiological  and  pathological  facts  and  by  the  results  ob- 
tained we  may  prove  the  correctness  or  fallacy  of  either  theory 
or  diagnosis. 

It  must  be  stated  that  there  are  limits  to  the  postulate 
of  substitution.  No  one  yet  lays  claim  to  curing  well  defined 
cases  of  Addison's  disease  by  any  method  or  form  of  adminis- 
tration of  any  part  or  of  the  whole  of  the  adrenal  gland  sub- 
stance. If  the  ovaries  are  removed  and  the  uterus  is  left  be- 
hind, no  amount  of  ovarian  or  other  extract,  no  matter  how 
given,  can  succeed  in  keeping  up  normal,  regular  menstruation. 

The  limitations  to  the  postulate  of  control  or  inhibition 
are  furnished  by  the  fact  that  our  knowledge  is  as  yet  only 
fragmentary — if  we  give  glandular  material  to  oppose  the 
activity  of  another  gland,  we  may  either  succeed  or  we  may 
rouse  that  or  other  glands  to  renewed  activity,  getting  what 
might  be  expressed  by  the  slang  phrase  "a  kick,  or  comeback." 

Another  theory  has  been  advanced  in  cases  of  overactivity 
of  a  gland,  namely,  that  by  giving  some  of  its  ow^n  extract  we 
relieve  the  gland  in  question  of  the  necessity  of  overAvork. 
This  technic  has  been  followed  by  some  workers  by  the  admin- 
istration of  thyroid  extract  in  hyperthyroidism  and  by  the 
administration  of  pituitary  extract  for  persistent  headache  In 
hyperplasia  of  the  pituitary  gland.  For  the  present  it  is  bet- 
ter to  leave  further  discussion  of  this  point  in  abeyance.  This 
idea  recalls  to  mind  the  much  more  rational  plan  of  giving  a 
gland  extract  w^hen  the  corresponding  gland  Is  overactive  and 
proving  the  correctness  of  our  diagnosis  by  looking  for  and 
finding  an  accentuation  of  the  annoyances.  Therefore  the  giv- 
ing of  thyroid  In  latent  hyperthyroidism  often  accentuates  the 
nervousness,  brings  on  a  tachycardia,  tremor  and  other  symp- 


140  THE    ENDOCRINES 

toms.  False  labor  pains  may  be  differentiated  from  real  ones 
by  the  action  noted  after  the  injection  of  pituitrin. 

When  the  study  of  endocrines  was  a  question  of  pathol- 
ogy and  physiology,  it  was  not  an  easy  problem  to  interest 
the  profession,  but  now  that  therapy  has  proved  to  be  so  valu- 
able, we  are  finally  on  the  road  to  further  investigations.  The 
most  important  fields  for  its  application  are  pediatrics,  mental 
diseases  and  gynecology.  I  believe  the  time  will  come  when 
the  majority  of  the  physical  and  mental  deficiencies  of  child- 
hood and  oi  the  adolescent  stage  will  be  treated  intelligently 
from  the  viewpoint  of  endocrine  secretions. 

I  hold  the  same  belief  concerning  the  field  of  mental  dis- 
eases (not  syphilis).  Here,  however,  progress  is  naturally 
bound  to  be  slow,  for  the  changes  are  gradual,  often  escaping 
observation  by  any  but  the  observing  in  their  early  periods. 
Exact  knowledge  concerning  the  effects  of  endocrines  on  the 
various  cerebral  areas  has  not  yet  been  revealed. 

The  greatest  advance  has  been  made  in  the  application  in 
gynecology.  First,  because  the  endocrines  dominate  the  physi- 
ology of  the  special  sex  functions  and  phenomena;  secondly, 
because  therapy  is  often  prompt  and  exact  and  convincing, 
when  prescribed  on  the  basis  of  physiology. 

Due  to  the  fact  that  many  states  are  now  recognized  as 
due  to  endocrine  abnormalities,  gland  extracts  viewed  simply 
from  the  viewpoint  of  therapeutics  have  replaced  many  of  the 
old-time  drugs  because  of  their  better  and  more  specific  action. 
For  instance,  we  no  longer  use  iron  and  arsenic  alone  in  the 
treatment  of  amenorrhea;  the  preparations  of  ergot  and  hy- 
drastis  have  been  replaced  by  gland  extracts,  in  the  treatment 
of  menorrhagia  and  metrorrhagia;  strychnine  and  allied  stimu- 
lants are  no  longer  relied  upon  exclusively  for  the  treatment 
of  various  forms  of  physical  asthenia.  Restriction  of  a  harm- 
ful diet  or  the  imposing  of  a  definite  diet  are  not  the  sole  fac- 
tors in  the  forms  of  malnutrition  of  children,  in  altered  meta- 
bolism of  adults,  and  in  the  treatment  of  obesity. 

Among  the  cases  best  treated  by.  endocrines  are  to  be 
included  the  patients  with  actual  and  relative  amenorrhea  as 


THE    EXDOCRIXES    IX    GYNECOLOGY  141 

well  as  lactation  atrophy;  menorrhagia,  metrorrhagia,  dys- 
menorrhea ;  sterility,  one  child  sterility ;  threatened  and  habitual 
miscarriage ;  disturbances  of  the  climacterium,  fibromyomata ; 
patients  suffering  from  hyperthyroidism  and  hypothyroidism, 
dispituitarism  and  similar  conditions.  Naturally  in  many  of 
our  patients  several  of  the  diagnostic  spheres  mentioned  above 
will  overlap.  The  readiness  with  which  one  may  undertake 
therapeutic  measures,  if  the  physiology  is  understood,  can  be 
well  instances  in  the  case  of  mammary  extract.  If  nursing  and 
suckling  result  in  involution,  then  why  not  use  mammary  ex- 
tract, not  only  for  this  purpose  but  for  many  of  the  forms  of 
regular  or  irregular  bleeding  and  for  certain  fonns  of 
fibromyomata  and  fibrosis. 

It  can  be  readily  appreciated  that  this  therapy  does  not 
give  the  same  definite  results  in  cases  of  apparently  the  same 
type,  if  we  only  consider  that  some  women  while  nursing  do 
not  menstruate  for  periods  of  six  months  or  a  year,  while 
others  menstruate  during  the  entire  period  of  lactation.  Pla- 
cental extract,  for  instance,  antagonizing  as  it  necessarily  doe? 
the  glands  whose  function  it  is  to  produce  menstruation,  may 
on  the  same  basis  be  used  for  certain  forms  of  overactivity  on 
the  part  of  the  thyroid,  ovary  and  pituitary  glands. 

It  is  more  than  probable  that  this  placental  secretion  plays 
its  part  in  the  causation  of  postpartum  asthenia  and  if  this  is 
true,  then  postpartum  asthenia  is  a  gland  exhaustion  and  since 
the  glands  most  affected  are  the  thyroid,  pituitary  and  adrenals, 
the  theory  on  which  therapy  is  to  be  established  becomes  ap- 
parent. It  is  the  whole  suprarenal  extract  which  is  of  value  in 
the  treatment  of  this  type  of  patient.  The  anterior  pituitary  is 
a  most  important  addition. 

The  treatment  of  the  curable  cases  of  sterility  by  endo- 
crines  depends  solely  on  the  trophic  stimulation  of  the  various 
structures  concerned  in  ovulation,  transmission  of  the  ovum, 
and  embedding  of  the  ovum ;  or  else  in  inhibiting  those  stimu- 
lations which  expel  the  ovum ;  and  our  brief  review  of  physi- 
ology makes  the  correct  application  of  the  appropriate  endo- 
crines  perfectly  clear.     Let  us  remember  that  the  interstitial 


142  THE    ENDOCRINES 

ovary  differs  from  the  follicle  apparatus  and  true  corpus  lu- 
teum;  the  anterior  hypophysis  from  the  posterior  pituitary; 
the  adrenal  cortex  from  the  medulla.  Possibly  within  these 
grosser  anatomical  and  physiological  differences  in  secretion 
are  still  finer  undefined  differences,  especially  in  various  periods 
and  functions  of  life. 

The  practice  of  gynecology  includes  gynecological  surgery, 
obstetrics,  and  conditions  amenable  to  treatment  by  what  are 
known  as  medical  methods.  But  in  addition  to  this  there  are 
types  characterized  not  only  by  somatic  signs,  but  by  what  are 
called  nervous,  neurasthenic  and  hysterical  and  psychic  symp- 
toms. Women  are  likely  to  refer  the  causation  of  their  gen- 
eral nervous  symptoms  to  the  genital  tract,  and  the  older  I 
grow  the  more  true  I  find  this  to  be.  Gynecologists  have  be- 
lieved this  to  be  the  case  and  have  evidenced  their  belief  by  the 
attention  paid  to  the  operative  correction  of  abnormalities  and 
injuries ;  and  by  the  added  explanation  that  through  reflex 
channels  these  deviations  from  the  normal  have  produced  their 
injurious  effect  on  distant  areas  of  the  body. 

Fifteen  years  ago  in  an  article  on  "Associated  Nervous 
Conditions  in  Gynecology,"  I  expressed  the  opinion  that  hy- 
perthyroidism, relative  and  actual,  was  the  most  frequent 
cause  in  my  practice  of  the  nervousness  and  excitability  in 
patients  called  hysterical  and  neurasthenic.  Continued  obser- 
vation taught  me  that  we  were  often  dealing  with  a  plus  or 
minus  thyroidism  and  that  in  a  general  way  the  excitable 
patients  were  suffering  from  a  thyroid  plus  condition  and  the 
depressed,  tired,  asthenic  patients  were  suffering  from  a  thy- 
roid minus  condition.  From  this  basis  further  experience 
showed  that  pluriglandular  involvement  was  frequent. 

Now  I  have  added  the  element  of  hyperpituitarism  to  the 
former  thought  of  hyperthyroidism  in  explanation  of  many  of 
the  excitable  states,  for  I  find  that  many  of  the  factors  which 
have  directed  my  attention  in  this  channel  point  to  the  pituitary 
body  in  explanation  of  physical  and  psychic  phenomena. 
Among  the  points  of  importance  are  dysmenorrhea,  menor- 
rhagia,   fibromyomata,    general    excitability,    lack    of   obesity. 


THE    ENDOCRINES    IN    GYNECOLOGY  143 

vasomotor  symptoms  and  symptoms  resembling  the  hysterical. 
I  might  refer  to  hysteron  from  which  Greek  word  is  derived 
the  word  hysteria.  The  theory  of  Freud  directed  to  the  study 
of  the  sex  sphere,  physical  and  psychic,  has  done  much  to 
attract  attention  to  the  importance  of  sex  questions  and  sex 
experiences  as  related  to  the  subsequent  behavior  of  the  indi- 
vidual. Before  passing  for  a  moment  to  the  question  of 
onanism,  let  me  state  that  I  believe  that  sex  phases  and  the 
phyche  are  not  wholly  matters  of  cause  and  effect  in  relation 
to  the  abnormalities  of  either,  but  that  both  are  projected  from 
stimulation  partly  of  an  endocrine  type  into  the  two  fields  of 
cognizance  and  sensation. 

Undoubtedly  the  greatest  difficulty  in  the  proper  inter- 
pretation of  interglandular  upsets,  depends  upon  the  fact  that 
so  many  of  them  are  of  minor  degree,  of  a  degree  less  than  is 
typical  of  the  well  exemplified  cases.  If  we  have  exophthalmic 
goitre  on  the  one  hand  and  myxedema  on  the  other ;  gigantism 
or  acromegaly  on  the  one  side,  certain  types  of  dwarfs  or 
dystrophia  adiposogenitalis  on  the  other  side ;  if  we  have  tetany 
and  paralysis  agitans  contrasting  with  myasthenia  gravis ;  if 
we  have  excessive  sexual  and  physical  development  due  to 
tumors  of  the  pineal,  the  hypophysis  and  the  adrenals  and 
gonads  on  the  one  hand,  and  cases  of  undeveloped  genitalia  and 
infantile  uterus  on  the  other ;  if  we  have  acromegaly  on  the  one 
hand  and  osteomalacia  on  the  other;  if  we  have  excessive  func- 
tion and  menstruation  through  oyster  ovaries,  and  diminished 
function  and  relative  amenorrhea  through  ovarian  hypoplasia 
and  degeneratio-adiposogenitalis ;  if  we  have  the  extreme 
adrenal  disease  known  as  Addison's  disease,  why  may  we  not 
expect  minor  degrees  of  involvement  in  the  glands  or  pluri- 
glands  responsible  for  these  major  cases,  the  resulting  symp- 
toms here  often  lacking  the  typical  earmarks  which  define  the 
standard  types  which  we  have  mentioned? 

We  must  distinguish  between  the  somatic  and  the  mental 
or  psychic  side  of  pathological  states  due  to  the  endocrine 
relation.  I  have  seen  attacks  of  mental  depression  and  blues 
in  so  many  of  my  patients ;  so  many  cases  of  premenstrual  ex- 


144  THE    ENDOCRINES 

citement  and  states  of  exaltation  of  minor  degree;  so  many- 
cases  where  the  states  vary  from  sHght  exaltation  to  slight 
depression  of  a  mild  melancholic  type ;  cases  of  puerperal  mania 
that  long  ago  I  came  to  the  conclusion  that  we  must  grant 
variations  in  intensity  in  mental  diseases. 

If  we  have  the  forms  known  as  manic  depressive  insanity, 
dementia  prsecox,  melancholia,  and  other  mental  deviations, 
why  may  we  not  have  minor  types  of  the  same  conditions  con- 
fronting us  in  our  medical,  gynecological  and  obstetrical  work  ? 
We  know  of  the  excitability  associated  with  the  various  grades 
of  hyperthyroidism ;  we  know  of  the  mental  apathy  associated 
with  the  various  degrees  of  myxedema;  we  know  the  mental 
peculiarities  and  the  changes  in  character  in  patients  with  hy- 
pophysis alterations.  All  of  these  alterations  noted  from  time 
to  time  in  my  experience  have  convinced  me  that  mental  dis- 
eases of  extreme  type  may  have  the  same  relation  to  the  milder 
forms  and  to  the  so-called  neuroses  and  psychoses,  and  to  the 
so-called  "neurasthenia"  and  "hysteria,"  that  the  major  forms 
of  exophthalmic  goitre  and  myxedema,  gigantism  and  dwarfism 
bear  to  minor  variations  noted  every  day. 

The  librarian  of  a  Scotch  university  once  remarked  that 
if  all  the  textbooks  ten  years  old  were  destroyed  little,  if  any- 
thing, would  be  lost.  Moynihan  says  :  "The  wealth  of  teach- 
ing in  the  textbooks  represents  rather  a  legacy  flowing  from 
one's  ancestors  than  a  fortune  newly  won  by  hard  endeavor." 

Endocrinology  is  making  such  vast  and  rapid  strides  that 
it  promises  to  overthrow  entirely  many  of  the  older  notions 
of  physiology,  pathology  and  therapy  in  our  textbooks.  It  is 
because  our  knowledge  on  many  points  is  so  indefinite  and  be- 
cause our  therapeutic  endeavors  are  so  groping  that  every 
medical  man  has  it  in  his  power  to  add  to  our  common  store  of 
information.  New  things  are  always  treated  with  skepticism, 
but  each  thinking  physician  may  observe  in  his  practice  abun- 
dant material  for  research.  By  working  together  we  may  soon 
prove  beyond  doubt  that  while  heredity  shapes  our  ends  there 
is  an  endocrinity  that  runs  parallel. 


THE   ENDOCRINES    IN    GYNECOLOGY  145 

A  difficult  question  and  one  requiring  the  utmost  delicacy 
in  its  management  is  the  question  of  onanism  and  abnormal 
sexual  practices.  The  general  idea  is  that  onanism  is  a  very- 
harmful  and  injurious  practice,  reacting  badly  on  the  physical, 
mental  and  psychic  sides  of  the  affected  individual.  That  it 
does  harm,  and  grievous  harm,  is  undoubtedly  true.  Is  it, 
however,  a  fact  that  degeneracy,  feeblemindedness,  and  weak- 
ness of  character  are  the  results  of  the  extremes  of  these  prac- 
tices, or  is  it  rather  that  in  these  types  these  habits  are  more 
frequently  observed  because  of  a  physical  trend  and  a  lack  of 
mental  control? 

We  are  confronted  with  a  like  problem  In  the  matter  of 
alcoholism.  It  is  certain  that  alcohol,  if  persistently  used  to 
excess,  has  an  injurious  effect  on  the  physical  and  mental  status 
of  an  individual.  If  tainted  with  a  tendency  to  degeneracy 
or  with  a  neuropathic  habitus,  it  exaggerates  the  trend  to  al- 
coholism and  increases  its  ill  effects ;  but  it  is  the  consensus  of 
medical  opinion  today  that  the  degenerate  and  feebleminded 
person,  the  hereditarily  tainted,  are  those  who  exhibit  the 
tendency  to  excessive  alcoholism,  and  therefore  many  view 
alcoholism  rather  as  a  symptom  of  abnormality. 

If  the  ovary,  thyroid,  pituitary  and  the  adrenals  have  to  do 
with  sex  development  and  with  a  trophic  control  and  support  of 
the  sex  organs,  it  would  seem  quite  natural  to  expect  a  hyper- 
sensitiveness  in  this  sphere,  and  a  more  easy  attraction  of  the 
mental  and  psychic  attention  toward  this  region  in  one  individ- 
ual than  in  another  not  so  stimulated.  A  rather  low  stimulation 
of  these  organs,  or  a  dominance  in  the  chain  on  the  part  of  those 
glands  which  inhibit  this  stimulation,  would  therefore  give  the 
opposite  effect.  Frigidity  is  as  often  caused  by  the  endocrines 
as  by  the  mental  attitude. 

Sexual  inclination  is  increased  or  diminished  at  different 
periods  of  life.  It  may  be  stimulated  by  food,  by  alcohol,  by 
drugs  or  through  various  senses.  Through  the  mental  sphere 
and  the  various  senses  an  exaggerated  stimulation  may  be  de- 
veloped. At  the  various  periods  intervening  between  men- 
struations sexual  inclination  varies,  it  is  increased  or  dimin- 


146  THE    ENDOCRINES 

ished  In  different  individuals  by  compatibility  or  Incompatibil- 
ity. If  disease  or  tumors  of  the  pineal  gland,  of  the  pituitary, 
or  of  the  adrenals  produce  precocious  sex  development,  how 
much  further  need  we  go  to  come  to  a  more  rational  con- 
clusion concerning  the  points  just  discussed  ?  This  conclusion 
is  based  more  on  the  theory  of  an  unrecognized  endocrine 
urge  than  we  have  heretofore  believed  possible. 

We  do  not  propose  the  idea  that  normal  man  is  not  re- 
sponsible for  his  acts.  I  do  not  propose  to  put  the  responsibility 
upon  the  endocrines  for  all  his  reactions  to  external  stimuli  and 
to  environment.  Instincts,  emotions,  education,  the  study  of 
high  moral  standards,  the  teaching  of  self-control  in  variou's 
ways,  the  element  of  duty  in  relation  to  one's  family  and  as  a 
protection  to  one's  self,  are  all  factors  which  develop  a  higher 
psychic  sense  of  control.  These  points,  together  with  the 
element  of  judgment,  distinguish  the  normal  from  the  lower 
grades  of  human  beings  and  from  animals;  but  to  say  that 
control  in  any  of  those  factors  that  dot  the  human  line  is  as 
easy  for  one  person  as  for  another  (even  granted  that  they 
have  the  same  parents  and  the  same  training)  is  to  say  that 
which  is  distinctly  not  true ;  for  It  is  not  true  that  all  men  are 
created  equal  in  instinct  and  potentialities. 

Some  persons  are  born  with  instincts  so  good  that  nothing 
can  make  them  bad ;  others  are  born  with  instincts  so  bad  that 
nothing  can  make  them  good;  but  the  vast  majority  of  people 
are  fairly  normal,  with  a  leaning  toward  one  or  the  other  side, 
according  to  their  endocrine  stimulation,  their  emotions,  their 
education,  training,  environment  and  accidents  of  experience. 
Change  the  words  good  and  bad  to  any  other  adjectives  imply- 
ing opposite  meanings,  and  a  like  statement  holds  good.  We 
may  say  of  people,  bright  or  dull,  energetic  or  lazy,  conserva- 
tive or  radical,  excitable  or  placid,  irritable  or  phlegmatic,  thin 
or  fat,  sweet  tempered  or  sour  tempered,  or  any  of  the  other 
adjectives  used  to  describe  characteristics. 

Some  people  are  born  with  so  stable  an  endocrine  relation 
that  nothing  will  alter  the  normal  interaction  of  the  endocrine 
glands;  others   Inherit  or  acquire  endocrines  so  unstable  or 


THE  ENDOCRINES   IN   GYNECOLOGY  147 

deficient  that  nothing-  can  elevate  them  to  the  threshold  of  the 
normal.  The  vast  majority  of  people  are  born  .with  a  fairly 
stable  endocrine  system  and  with  instincts  capable  of  being  af- 
fected for  better  or  for  worse  by  the  influences  and  accidents 
and  infections  of  life. 

The  relation  between  the  various  endocrine  structures 
is  less  stable  in  woman  than  in  man.  There  are  many  dis- 
turbances during  the  period  of  development  and  the  establish- 
ment of  menstruation.  Menstruation  itself  is  a  constitutional 
phenomenon,  associated  with  loss  of  blood,  often  with  dysmen- 
orrhea, often  with  severe  premenstrual  phenomena.  Preg- 
nancy, while  it  acts  as  a  tonic  in  most  cases,  in  many  instances 
puts  too  great  a  strain  on  the  endocrine  chain.  Miscarriage, 
while  well  borne  even  when  repeated  in  many  instances,  is  in 
other  instances  productive  of  lasting  harm  to  the  ovaries.  In- 
flammation affecting  the  uterus  and  the  ovaries  may  have  an 
important  bearing  on  an  endocrine  upset.  The  same  holds  true 
of  uterine  displacements  because  of  the  involvement  of  the 
ovaries.  The  hypophysis  changes  in  pregnancy  are  latent  pos- 
sibilities of  future  troubles. 

Tumors  of  the  genitalia,  whether  they  are  the  result  of 
endocrine  aberrations  or  not,  are  certainly  associated  with 
inharmonious  action  of  associated  glands.  The  change  of  life 
phenomena,  profound  as  they  are  in  many  instances,  are  an 
evidence  of  the  inherent  instability  present  in  many  women.'  In 
a  goodly  number  of  women  there  is  a  normal  readaptation 
but  it  is  at  this  period  that  previously  latent  weaknesses  rise 
to  the  surface.  The  psychic  effect  of  the  various  happy  and 
unhappy  complications  of  life  are  not  to  be  underestimated. 
Because  of  these  possibilities  woman  is  called  the  weaker  sex. 
It  must  be  granted,  however,  that  in  the  largest  proportion  of 
cases  she  does  mighty  well  to  hold  her  own.  \^^hatever  we 
may  say  about  thyroid  affections  it  is  a  fact  that  this  gland  is 
involved  eight  to  ten  times  as  often  in  women  as  in  men.  The 
influence  and  activity  of  the  endocrine  glands  are  evidenced 
by  the  stimuli  and  the  changes  produced  on  the  body,  the 
nervous  system,  the  emotions  and  the  psyche.     In  some  in- 


148  THE    ENDOCRINES 

stances  abnormalities  of  gland  activity  are  characterized  by 
physical  stigmata;  in  others,  by  changes  in  the  activity  of  or- 
gans whose  function  is  continually  under  the  influence  of  the 
nervous  system.  In  still  other  individuals,  abnormalities  of 
gland  activity  are  evidenced  by  changes  in  the  psyche;  and  in 
some,  combinations  of  various  forms  are  in  evidence. 

When  events,  occurrences,  etc.,  which  act  on  the  instincts 
and  arouse  emotions  do  prompt  a  response,  there  is  an  en- 
docrine activity  which  varies  in  degree  and  in  the  gland  in- 
volved according  to  the  instinct  and  emotion  affected,  and  this 
particular  endocrine,  or  endocrines,  act  as  fixers  in  association 
with  the  thyroid. 

A  distinct  neuroendocrine  path  is  created  by  every  stimu- 
lus through  any  of  the  senses.  Any  event,  process,  or  stimulus 
which  has  brought  into  activity  any  endocrine  secretion  spe- 
cifically associated  with  the  emotion  aroused,  may  be  recalled, 
or  the  recall  is  made  more  easy  by  a  subsequent  activity  of  that 
endocrine.  This  constitutes  what  might  be  called  reverse 
peristalsis,  and  plays  the  all-important  part  in  dreams,  and  in 
determining  the  character  of  the  dreams. 

If  a  little  child  three  years  old,  before  retiring.  Is  aroused 
into  a  tempest  of  anger  by  anyone  and  a  few  hours  later  that 
little  child  in  its  dream  shows  the  emotion  of  anger  and  cries 
out  the  name  of  the  person  responsible  for  the  emotion,  how 
are  we  to  explain  this  phenomenon?  What  more  logical  and 
correct  explanation  can  we  give  than  that  the  adrenal  outpour- 
ing associated  with  the  emotion  of  anger  has  continued  its 
activity  during  sleep  and  has  reawakened  the  subconscious 
sphere  and  in  part  the  upper  sphere,  to  a  reproduction  of  the 
original  picture?  Considerations  like  these  should  make  us 
regard  the  bedtime  hour  of  children  as  the  hour  of  their  great- 
est happiness.  If  certain  fairy  tales  and  stories  that  unwittingly 
rouse  fear  were  banished  entirely  from  the  lives  of  children  the 
adult  would  have  fewer  phobias,  fears,  and  anxieties. 

If  we  can  fathom  and  understand  what  the  ductless  glands 
have  done  to  an  individual,  born  with. instincts  and  emotions, 
up  to  the  stage  of  puberty,  we  may  better  appreciate  why  the 


THE   ENDOCRINES    IN    GYNECOLOGY  149 

individual  develops  as  he  does;  if  we  can  reason  out  what 
these  ductless  glands  have  done  to  that  individual,  with  instincts 
and  emotions,  from  puberty  up,  we  may  better  understand  why 
that  individual  is  what  he  is  and  why  so  many  changes  have 
occurred  in  him;  if  we  can  eventually  fathom  what  hereditary 
or  accidental  and  intercurrent  factors  a/e  responsible  for  his 
endocrine  relations  and  for  the  consequent  emotional,  systemic, 
mental,  and  psychic  factors,  then  medicine  will  have  achieved 
a  glorious  work.  And  when  we  finally  realize  that  the  emo- 
tions act  on  the  endocrines  and  that  the  endocrines  influence 
and  produce  emotions  much  that  is  mysterious  will  seem 
simple. 

I  should  like  to  warn  against  the  tendency  to  prescribe 
definitely  combined  formulae  in  tablet  or  other  form,  when 
such  combinations  are  recommended  as  the  correct  therapy 
for  certain  and  many  of  the  conditions  now  known  to  be 
due  to  endocrine  abnormality.  The  physician  then  loses 
touch  with  the  theory  an^'  explanation  of  the  innumerable 
pluriglandular  states  and  the  study  and  analysis  of  all  the 
factors  entering  into  diagnosis  are  neglected.  In  the  past  this 
has  been  a  serious  hindrance  to  accurate  diagnosis  and  to  the 
proper  interpretation  of  the  therapeutic  value  of  the  drugs 
entering  into  many  of  the  combinations.  The  physician  ought 
not  to  further  the  habit  among  the  laity  of  taking  drugs  of  any 
sort  except  on  medical  advice,  for  if  he  does  anything  to  foster 
this  habit  he  will  be  more  and  more  looked  upon  as  a  man 
needed  only  for  advice  and  help  in  those  states  and  conditions 
which  the  public  feel  they  cannot  correctly  diagnose  and  treat 
alone. 


CHAPTER    VI 

HYPERGENITALISM  AND  HYPOGENITALISM 

Hypergenitalism  (Pubertas  Praecox) 

The  somatic  and  psychic  characteristics  of  puberty  are  de- 
pendent to  a  great  extent  upon  and  evidenced  by  the  maturity 
of  the  genital  glands. 

Premature  puberty  includes  accelerated  ossification.  Skia- 
grams show  a  rapid  approach  of  epiphyseal  ossification  to  the 
stage  when  the  synarthroses  close.  This  finding  is  in  accord- 
ance with  that  of  psysiologic  puberty,  for,  in  the  latter  condi- 
tion, proliferation  of  the  epiphyses  soon  ceases.  Gigantism, 
on  the  contrary,  is  characterized  by  persistence  of  epiphyseal 
synarthroses  and  by  the  abnormal  height  to  which  this  leads 
(Biedl). 

The  most  important  point  in  regard  to  the  etiology  of 
pubertas  prsecox  is  whether  or  not  the  condition  is  primarily 
the  outcome  of  precocious  development  of  the  genital  glands. 
Hypergenitalism  and  pubertic  precocity  may  be  primary  or  else 
the  secondary  results  of  the  primary  affection  of  other  glands. 
This  applies  to  cases  in  which  tumors  were  present,  either  in 
the  suprarenals,  in  the  hypophysis,  or  the  pineal  glands. 

Hypophyseal  overactivity  is  frequently  associated  with  gi- 
gantism, although  generally  with  genital  atrophy. 

Cases  of  pineal  tumor  show  abnormal  growth  in  height 
and  premature  genital  and  sexual  development  and  correspond- 
ing mental  precocity. 

The  presence  of  suprarenal  tumor  in  sexual  precocity  is 
remarkably  frequent.  There  is  exceptional  development  of 
the  body,  obesity,  physical  precocity,  the  habit  of  sexually 
mature  persons,  extreme  hypertrichosis. 

If  we  exclude  such  observations,  a  large  number  of  cases 
remain  which  cannot  be  explained  otherwise  than  by  primary 
hypergenitalism. 

The  genital  glands  have  a  great  effect  upon  the  growth 
of  the  skeleton.     Experiments  show  that  in  man  as  in  animals 

150 


HYPERGENITALISM   AND    HYPOGENITALISM  151 

castration  is  followed  by  excessive  longitudinal  growth,  a  lack 
of  proportion  between  the  length  of  the  extremities  and  that 
of  the  trunk,  and  persistence  of  the  epiphyseal  synarthroses 
beyond  the  normal  age. 

Protracted  epiphyseal  separation  may  result,  not  only 
from  the  operative  removal  of  the  generative  glands,  but  also 
from  hypoplastic  subdevelopment  of  them.  The  presence  of 
this  symptom,  in  combination  with  the  persistence  of  other 
juvenile  traits,  is  described  as  immaturity  of  the  organism  or 
eunuchoidia.  These  cases  do  not  altogether  fall  into  the  group 
of  pathologic  conditions  classed  as  infantilism,  for  infantilism 
is  characterized  by  the  small  size  of  the  skeleton  and  its  infan- 
tile proportions ;  i.  e.,  long  trunk  and  short  extremities.  Hypo- 
plasia of  the  genital  glands  is  presumably  accompanied  by 
symptoms  analogous  to  those  of  suppression;  i.  e.,  abnormal 
longitudinal  growth,  especially  in  the  legs,  and  considerable 
increase  in  the  fat  of  the  body.  Thus,  the  only  true  cases  of 
hypogenitalism  would  be  those  of  infantile  gigantism,  which 
are  characterized  by  abnormal  growth  of  the  long  bones,  im- 
perfect secondary  sex  characteristics,  and  deficient  mental  de- 
velopment, and  in  which  testicular  atrophy  and  the  absence  of 
any  signs  of  pituitary  disease  justify  the  assumption  of  primary 
hypogenitalism.     (Biedl.) 

The  age  in  which  genital  maturity  takes  place  has  a  para- 
mount influence  upon  the  growth  of  the  skeleton.  The  effect 
of  late  maturity,  like  that  of  genital  hypoplasia,  is  to  increase 
the  height,  especially  the  length  of  the  legs,  while  early  ma- 
turity brings  about  premature  closing  of  the  epiphyses,  and  is 
consequently  associated  with  shortness  of  the  legs.  Inhabitants 
of  warm  countries  are  generally  small  of  stature.  These  re- 
sults are  to  be  attributed  to  early  sexual  maturity. 

There  is  intimate  relationship  between  the  development  of 
the  skeleton  and  the  internal  secretory  activity  of  the  genital 
glands.  The  genital  glands  elaborate  a  hormone,  which  stimu- 
lates the  processes  of  ossification.  Castration  is  followed  by 
changes  in  the  thyroid,  thymus,  adrenals,  and  hypophysis,  and 
the  removal  of  these  organs  produces  changes  in  the  struc- 


152  THE    ENDOCRINES 

ture  of  the  genital  gland.  It  is,  therefore,  very  difficult  to 
estimate  the  extent  to  which  the  skeleton  is  directly  influenced 
by  the  genital  glands,  because  the  thymus,  thyroid,  adrenals, 
and  hypophysis  all  effect  the  growth  of  the  bone,  their  com- 
bined influence  being  complicated ;  in  part  antagonistic,  in  part 
co-operative. 

Hypogenitalism  (Sexual  Infantilism) 

Infantilism  includes  a  group  of  variations  which  differ 
very  much,  but  which  include  various  degrees  of  retardation 
of  development.  In  addition  to  that  retardation  which  affects 
certain  organs,  or  which  affects  certain  systems  (such  as  the 
osseous  system,  the  cardiovascular  system,  or  the  nervous  sys- 
tem, or  the  sexual  organs,  or  which  constitutes  a  general 
retardation  of  development),  there  is  the  retardation  which 
is  functional  rather  than  organic.  An  arrest  of  development 
which  affects  the  mass  of  the  individual  may  result  from  vari 
ous  causes,  from  infections,  such  as  infections  of  the  cardiac 
or  arterial  systems.  A  normal  development  may  be  inhibited 
by  transmission  of  hereditary  faults,  or  by  errors  of  hygiene 
during  infancy  and  early  childhood.  Infantilism  may  result 
from  anemia  and  chlorosis,  from  tuberculosis  or  lues,  or  from 
intestinal  conditions,  as  mentioned  by  Herter. 

Infantilism  includes  alterations  in  the  osseous  system, 
such  as  slight  body  development,  gracile  bone  development, 
deformities  of  the  skull,  hypoplasia  of  the  jaw,  irregular  tooth 
development,  and  the  various  degrees  of  skeletal  undergrowth. 
There  results  delicacy,  smallness  of  the  body,  and  the  individual 
is  an  adult  in  small  mold. 

Infantilism  has  been  considered  an  anomaly  of  develop- 
ment, in  which  the  general  morphologic  characteristics  belong- 
ing to  infancy  persist  in  a  subject  who  has  passed  the  age  of 
puberty.  Thus  infantilism  formerly  signified  a  persistence  of 
infantile  characteristics.  This  view  included  other  elements 
in  addition  to  stature,  and  to  the  element  of  skeletal  under- 
growth was  added  variations  in  the  development  of  the  gen- 
erative organs  of  the  degree  of  sexual  dystrophy. 


HYPERGENITALISM    AND    HYPOGENITALISM  153 

Today  we  are  inclined  to  consider  under  infantilism  a 
retardation  of  development  that  may  begin  at  any  age,  and 
results  in  the  persistence  of  the  physical  characteristics  that 
exists  at  the  age  of  its  onset.  It  means  that  development  re- 
mains stationary  at  a  stage  which  a  normal  individual  of  the 
same  age  has  long  passed.  This  unripeness,  just  as  it  may 
affect  the  entire  organism,  may  also  affect  only  certain  organs 
(infantilismus  partialis)  or  certain  organ  systems,  or  else  it 
may  affect  the  entire  organism  (infantilismus  universalis). 
Development  of  any  organ  concerns  a  differentiation  in  ex- 
ternal and  internal  form,  also  a  change  in  size,  also  a  change 
in  position,  so  that  an  inhibition  of  growth  may  concern  the 
form  (horseshoe  kidney),  size  (narrow  aorta),  or  position, 
undescended  testicle  (cryptorchism). 

Though  a  retardation  of  development  may  manifest  itself 
in  a  retardation  of  development  of  the  osseous  system  or  the 
nervous  system,  or  the  cardiovascular  system  or  the  sexual 
organs,  it  does  not,  by  any  means,  affect  equally  all  parts. 
Infantilism  may  also  signify  retardation  in  functional  develop-, 
ment,  and  this  may  be  general  or  confined  to  certain  systems, 
or  may  be  local ;  hence,  asthenia  universalis  congenita  is  a 
functional  form  of  infantilism,  as  is  visceroptosis,  so  is  flat-foot, 
and  so  are  other  forms  of  asthenia. 

Many  of  the  pictures  under  the  heading  of  Infantilism 
have  been  such  as  resulted  from  the  effects  of  hypothyroidism. 

Hypothyroidism  inhibits  the  growth,  especially  of  the 
long  bones,  associated  with  which  is  the  tendency  to  become 
more  stout  and  plump.  There  are  changes  in  the  growth  of 
hair;  there  is  enlargement  of  the  abdomen,  diminution  of  the 
temperature,  there  is  a  mucoid  edema  of  the  subcutaneous  tis- 
sue, atheromatous  changes  in  the  aorta;  there  is  genital  hypo- 
plasia, sterility,  and  idiocy.  These  are  observed  where,  in  ani- 
mals or  human  beings,  there  is  a  complete  defect  of  the  thy- 
roid. These  changes  are  especially  noted  in  absence  of  the 
thyroid  in  young  animals  still  in  the  early  periods  of  growth. 
In  older  animals  the  changes  are  less  marked.  The  animals 
then  show  apathy,  trophic  disturbances  of  the  skin,  alterations 


154  THE    ENDOCRINES 

in  digestion,  loss  of  weight,  anemia,  and  a  disposition  to  in- 
fectious diseases^  to  which  they  readily  succumb.  The  genital 
functions  are  diminished. 

The  same  changes  occur  in  human  beings  after  removal  of 
the  entire  thyroid.  This  is  the  so-caUed  cachexia-strumipriva. 
A  further  symptom  of  this  cachexia  is  a  diminution  of  the  men- 
tal energy,  of  the  energy  for  work,  and  a  typical  edematous 
swelling  of  the  skin.  The  skin  is  dry  through  a  diminution  of 
the  perspiration,  the  hair  falls  out,  the  patients  look  old  and 
stupid,  the  red  blood-cells  are  diminished. 

In  congenital  myxedema  there  is  a  decided  inhibition  of 
growth.  There  is  obstinate  obstipation,  psychic  disturbances, 
and  a  marked  inhibiting  effect  on  the  sexual  organs.  In  the 
congenital  absence  of  the  thyroid  and  in  the  infantile  cases 
of  atrophy  of  the  thyroid  (which  atrophy  develops  in  the  fifth 
and  sixth  years),  the  large  majority  of  the  cases  are  found  in 
female  children.  Myxedema  in  adults  is  more  frequent  than 
infantile  myxedema.  At  that  period  80  per  cent,  of  the  cases 
are  in  women.  Here  anomalies  in  the  function  of  the  female 
genitalia  are  frequent.  Amenorrhea  is  frequent,  but  menor- 
rhagia  also  occurs ;  in  many  cases  the  genitalia  remain  normal ; 
in  other  cases  a  decided  atrophy  is  found. 

Infantilism  is  probably  always  the  result  of  alterations  or 
deficiency  in  glandular  functions.  It  may  result  from  the  so- 
called  status  lymphaticus,  where  fatty  marrow  is  present  in- 
stead of  red-bone  marrow.  It  may  result  from  persistence  of 
the  thymus,  insufficiency  of  the  thyroid  or  faulty  secretion  of 
the  suprarenals,  or  pancreatic  insufficiency,  or  deficiency  of 
the  hypophysis  or  ovaries,  or  chromaffin  tissue. 

Involution  of  the  thymus  coincides  normally  with  adoles- 
cence. There  may,  however,  be  the  so-called  persistent  thy- 
mus. The  thymus  exercises  an  inhibitory  influence  upon  the 
development  of  the  ovaries,  and  involution  of  the  thymus  is 
consequent  upon  the  maturity  of  the  sexual  glands.  Individ- 
uals with  hypoplastic  ovaries  retain  the  thymus  longer  than 
normal.  In  this  form  of  status  thymicus  there  is  a  question 
whether  the  thymus  is  in  direct  relation  with  the  genitalia, 


HYPERGENITALISM   AND    HYPOGENITALISM  155 

or  whether  both  are  not  a  symptom  of  a  slow  development. 
In  the  status  thymicus  there  is  a  general  enlargement  of  the 
lymph-glands,  of  the  tonsils,  of  the  follicles  at  the  base  of  the 
tongue,  enlargement  of  the  spleen,  narrow  aorta,  large,  pale, 
soft  heart.     (Biedl.) 

If  with  infantile  signs  in  the  body  there  is  genital  hypo- 
plasia, with  late  menstruation,  narrow  pelvis,  large  tonsils, 
possibly  slight  Basedow  symptoms,  we  must  always  think  of 
the  "status  lymphaticus." 

Vascular  hypoplasia,  with  narrow  aorta,  may  be  present 
with  or  without  chlorosis.  In  vascular  hypoplasia  anomalies 
of  genital  functions  may  occur.  Menstruation  develops  late, 
there  are  various  forms  of  dysmenorrhea  or  amenorrhea, 
though  occasionally  there  may  be  bleedings  at  puberty.  When 
genital  and  vascular  hypoplasia  exist  in  the  same  individual, 
they  must  be  considered  as  co-ordinated  results  of  a  general 
disturbance  of  development  dependent  on  the  endocrines. 

Absence  of  or  alterations  in  the  internal  secretion  of  the 
ovaries  may  be  the  cause  of  infantilism.  The  type  varies  ac- 
cording to  the  period  at  which  changes  occur.  Castration  of 
young  animals  arrests  the  development  of  the  genital  organs; 
castration  of  adults  changes  only  the  secondary  sexual  charac- 
teristics. Therefore,  infantilism  may  be  a  regressive  change, 
occurring  after  atrophy  of  the  ovaries.  Atrophy  of  the  ovaries 
may  be  secondary  to  affections  of  the  hypophysis  and  thyroid 
and  adrenals.  Involvement  of  the  hypophysis  causes  a  typical 
type  of  infantilism,  with  a  disappearance  of  the  sexual  charac- 
teristics. The  size  of  the  individual  should  not  lead  to  wrong 
conclusions,  for  early  development  of  the  ovaries  causes  early 
ossification,  and  so  limits  the  height  of  the  individual,  while 
absence  or  late  development  may  delay  ossification,  and  cause 
increased  length  of  the  lower  extremities.  The  secretion  of  the 
ovaries  assures  the  development  of  the  genital  organs  and  the 
appearance  and  the  continuation  of  the  secondary  sex  char- 
acteristics, so  that  congenital  or  early  involvement  of  the 
ovaries  may  prevent  the  development  of  the  secondary  sex 
characteristics. 


156  THE    ENDOCRINES 

Hypoplasia  of  the  ovaries  may  represent  only  one  of  the 
symptoms  of  a  constitutional  anomaly  for  which  it  is  not  re- 
sponsible. This  is  not  infrequently  found  as  a  part  of  a  general 
condition  in  patients  who  have  a  tendency  to  enteroptosis,  mov- 
able cecum  and  sigmoid,  a  lack  of  fat  on  the  large  labia,  a  large 
distance  between  clitoris  and  urethra,  narrow,  short  vagina,  a 
lack  of  well-developed  fornices,  malposition,  rudimentary  uterus 
or  infantile  or  fetal  uterus  (cervix longer  than  the  corpus),  vari- 
ous degrees  of  double  or  divided  uterus,  small  ovaries.,  narrow 
pelvis,  persistence  of  fine  hair  on  the  lips,  and  diminished 
trichosis  of  the  axilla.  There  is  frequently  dysmenorrhea. 
There  is  often  fluor  albus.  There  is  a  tendency  to  vaginismus, 
often  sterility,  and  a  resulting  phychic  depression.  There  is 
decided  asthenia. 

"The  interrelation  between  the  hypophysis  and  ovary  is 
very  intimate.  Cases  show  imperfectly  acquired  secondary 
sexual  characteristics  when  the  hypophyseal  lesions  antedate 
puberty,  and  a  resultant  amenorrhea,  with  retrogressive  sexual 
changes,  when  the  malady  develops  after  adolescence.  As  a 
result  of  preadolescent  castration,  reproduction  is  impossible 
and  the  acquired  characteristics  of  sex  fail  to  appear.  In  the 
ovary  there  are  two,  and  possibly  three,  glandular  elements, 
the  gland  of  ovulation,  the  interstitial  cell  body,  and  the  cor- 
pus luteum  of  menstruation  and  of  pregnancy.  The  reproduc- 
tive function  may  not  be  impaired,  even  though  full  secondary 
sexual  characteristics  have  not  been  acquired.  The  secretory 
element  of  the  ovary,  which  is  responsible  for  the  physical 
changes  of  puberty,  is  probably  the  interstitial  body,  and  dif- 
fers from  that  which  is  concerned  with  ovulation.  The  re- 
lation of  hypophyseal  disorders  of  overfunction  or  underfunc- 
tion  to  physiologic  activities  of  the  ovary,  other  than  those 
concerned  with  the  acquirement  of  adolescent  characteristics, 
is  very  close,  and  amenorrhea  is  an  early  symptom,  with  marked 
overfunction  or  underfunction." 

When  hypopituitarism  of  the  anterior  lobe  dates  from 
the  adolescent  period  there  occur  other  changes  than  failure 
of  full  development  of  the  long  bone.     There  occurs  in  the 


HYPERGENITALISM   AND    HYPOGENITALISM  157 

male  a  feminine  disposition  of  the  adiposis,  the  males  possess 
a  feminine  type  of  skeleton  with  broad  pelvis,  there  are  small 
and  delicate  extremities,  there  is  the  tapering  type  of  hand. 
In  hypopituitarism  there  is  a  certain  undefinable  facial  resem- 
blance, due  to  maxillary  prognathism,  while  in  acromegaly 
there  is  mandibular  prognathism. 


CHAPTER  Vn 

SKIN  AFFECTIONS  AND  THE  INTERNAL 
SECRETIONS 

The  thyroid,  the  adrenals,  the  ovaries,  the  hypophysis, 
and  the  other  glands  act  .to  some  extent  in  harmony,  to  some 
extent  in  opposition,  to  each  other.  In  diseases  one  may  take 
up  the  function  of  the  other,  or  they  may  all  unite  in  a  com- 
mon action  against  certain  products,  some  or  all  may  be  affected 
in  like  or  varying  degrees  by  infections  or  by  toxic  substances. 

Politzer's  conclusions  are  of  great  interest  and  are  sub- 
stantially as  follows :  Certain  involvements  of  the  skin  occur 
during  pregnancy  and  disappear  on  termination  of  pregnancy. 
There  are  certain  dermatoses  of  puberty,  of  menstruation,  of 
pregnancy,  and  of  the  climacterium.  Some  of  the  skin  annoy- 
ances of  pregnancy  may  depend  on  the  cessation  of  ovarian 
function  and  the  cessation  of  menstruation  during  that  time, 
or  they  may  be  due  to  the  influence  of  the  corpus  luteum  or  of 
the  placenta  or  the  pituitary  or  the  adrenals. 

At  puberty  there  is  a  great  change  in  the  skin ;  there  is  a 
special  increase  in  the  adipose  tissue  characteristic  of  the  fe- 
male; there  is  a  growth  of  hair  In  the  pubic  and  axillary 
region.  Acne  may  be  considered  as  related  to  the  sexual  ap- 
paratus only  in  so  far  as  the  establishment  of  puberty  physiolog- 
ically brings  about  local  circulatory  changes  in  the  skin  of  the 
face,  which  renders  the  latter  a  more  favorable  soil  for  the 
development  of  the  special  micro-organisms  of  acne. 

The  regular  monthly  hyperemia  of  menstruation  may  oc-. 
cur  in  any  part  of  the  body,  and  cause  dilation  of  the  blood- 
vessels in  any  part  of  the  body,  may  cause  changes  in  any  of 
the  skin  diseases,  or  altered  skin  conditions,  which  are  present 
in  face  and  elsewhere.  Simple  erythema  and  the  various  forms 
up  to  erythema  nodosum  may  occur  regularly  before,  during, 
or  after  menstruation,  and  are  often  associated  with  menstrual 
irregularities.  Cases  of  purpura  in  connection  with  menstrual 
irregularities  may  be  regarded  as  due  to  pathologic  processes 

158 


SKIN  AFFECTIONS  AND  THE  INTERNAL  SECRETIONS       159 

in  the  skin  of  a  more  intense  nature  than  those  which  cause 
erythema. 

Urticaria  and  angioneurotic  edema  may  be  related  to 
menstruation.  Menstrual  urticaria  may  appear  at  regular  in- 
tervals with  each  monthly  period ;  in  other  cases  it  occurs  only 
with  menstrual  irregularities,  such  as  amenorrhea.  The 
angioneurotic  edema  not  infrequently  occurs  in  definite  rela- 
tion to  menstruation;  they  may  be  anaphylactic  phenomena. 
The  most  frequent  skin  disorder  related  to  menstruation  is 
herpes.  One  woman  in  twenty  suffers  from  frequent  or  habitual 
menstrual  herpes,  occurring  on  the  external  genitalia  or  in  the 
sacral  region  or  the  face,  especially  the  lips. 

Hypertrichosis  (excessive  development  of  hair),  more  or 
less  over  the  entire  surface,  but  especially  in  the  face,  is 
pathologic;  it  is  commonly  associated  with  ovarian  disorders 
and  is  due  to  the  adrenal  cortex  and  the  anterior  pituitary. 
Disturbances  in  the  function  of  the  ovaries  produce  changes  in 
the  suprarenals  and  hypophysis.  Temporary  cessation  of  ovar- 
ian functions  during  pregnancy  causes  increased  secretion  of 
the  hypophysis  and  adrenals.  Hypertrichosis  has  been  said  to 
be  due  to  the  excessive  function  of  the  hypophysis  and  adrenals. 
Hypertrichosis  of  puberty,  the  hypertrichosis  of  ovarian  disease, 
and  the  hypertrichosis  of  the  climacterium  are  due  to  inade- 
quate glandular  ovarian  secretion  acting  in  this  manner. 

Hyperpigmentation  at  puberty,  during  pregnancy,  and 
with  ovarian  disease  is  not  infrequent.  Chloasma  gravidarum 
occurs  in  three-quarters  of  pregnant  cases.  It  is  possible  that 
the  placental  secretion  produces  secondary  changes  in  the  func- 
tion of  the  adrenals. 

Herpes  gestationis  is  a  severe  disease,  characterized  by  an 
eruption  of  more  or  less  extensively  distributed  grouped  lesions, 
made  up  mainly  of  vesicles  and  bullse  accompanied  by  intense 
pruritus.  The  disease  is  dependent  on  pregnancy,  and  promptly 
disappears  when  the  uterus  is  emptied. 

It  was  formerly  suggested  that  the  pruritus,  urticarias,  and 
dermatitides  of  pregnancy  are  due  to  the  same  agents  that 
cause  hyperemesis,  nephritis,  hepatitis,  and  eclampsia;  namely. 


160  THE    ENDOCRINES 

anaphylaxis  brouj^ht  about  through  absorption  of  foreign  pro- 
teids  from  the  placenta.  Endocrine  changes  are  involved  in 
all  these  conditions.  Some  cases  of  dermatoses  in  pregnant 
women  have  been  relieved  by  the  injection  of  20  c.c.  to  30  c.c. 
of  serum  from  the  blood  of  healthy  pregnant  women. 

The  dermatoses  of  the  climacterium,  so  far  as  they  are 
related  to  the  genital  system,  are  of  the  same  kind  and  nature 
as  those  occurring  with  anomolies  of  menstruation  and  are  de- 
pendent on  altered  endocrine  secretions.  At  any  rate  "reflex" 
has  nothing  to  do  with  these  cases  of  skin  involvement. 


CHAPTER    VIII 
PUBERTY   AND    CLIMACTERIUM 

Up  to  and  before  the  period  of  pubescence  the  gland- 
ular or  follicular  portions  of  the  ovary  have  not  been  active 
as  far  as  menstruation  is  concerned, — at  least  not  as  a  rule. 
The  interstitial  and  glandular  ovaries  have,  however,  been 
performing  some  of  the  functions  which  are  related  to 
the  development  of  the  secondary  sex  characteristics,  the 
most  noticeable  of  which  characteristics  are  the  future  mam- 
mary glands.  If  we  at  this  time  compare  the  frame,  outline, 
and  typical  locations  of  fat  distribution  of  the  boy  and  girl 
we  see  differences  sufficiently  marked  to  realize  that  they, 
as  well  as  the  differences  in  tastes  and  emotions,  are  due  to  the 
fact  that  the  ovaries  in  the  girl  and  the  gonads  of  the  boy  must 
be, — as  they  are, — among  the  responsible  factors  and  that 
these  differences  have  occurred  through  the  medium  of  the 
ovaries  on  the  one  hand  and  the  testes  on  the  other.  Up  to 
this  time,  too,  pineal  gland,  the  hypophysis,  the  para-thryroids, 
the  thymus,  the  thyroid,  the  adrenals,  etc.,  have  been  contribut- 
ing their  internal  secretions,  making  and  moulding  the  child's 
body,  visceral,  and  sex  structures,  and, — what  is  not  least  in 
importance, — the  mind  or  psyche. 

The  anterior  pituitary  is  especially  related  to  the  growth 
of  the  frame,  of  muscle  and  the  development  of  the  brain; 
the  posterior  pituitary  is  particularly  related  to  the  devel- 
opment of  the  sex  organs,  muscular  structures,  and  to  meta- 
bolic processes,  etc.;  the  thyroid  is  the  great  activator;  and 
the  normal  action  of  the  thyroid  i^  of  the  greatest  im- 
portance in  promoting  those  trophic  and  nutritional  changes 
in  the  brain  which  lead  to  the  development  of  a  good 
mind,  good  memory,  etc.  An  under-activity  of  the  thyroid 
is  responsible  not  only  for  retarded  physical  growth  and  for 
the  various  degrees  of  myxodema  and  cretinism  in  children, 
so  often  seen  but,  in  the  absence  of  all  physical  manifestations 
of  a  marked  character,  it  is  responsible  for  mental  sluggish- 

161 


162  THE   ENDOCRINES 

ness,  for  inertia,  for  lack  of  energy.  Such  children  tire  easily 
over  physical  or  mental  work,  are  sleepy  or  slow  in  their  move- 
ments, they  yawn  over  their  school  work,  they  get  up  late 
and  dress  slowly,  and  are  quite  different  from  the  normal, 
healthy,  active  child,  anxious  to  go  about  its  work.  These 
children  are  scolded  and  called  lazy,  stupid,  "fat-head/'  when 
all  they  need  is  the  recognition  of  the  condition  and  the  ad- 
ministration of  thyroid  extract  or  pituitary  anterior  or  supra- 
renal extract  in  small  doses. 

The  hyper-thyroid  child  is  over-stimulated,  over-ener- 
getic, often  extremely  excitable,  readily  irritated.  So  is  the 
child  with  excessive  action  of  the  adrenal  medulla  or  of  the 
posterior  pituitary. 

The  adrenal  function  is  of  the  greatest  importance  during 
this  period  of  development,  not  only  because  it  is  essential 
to  good  health,  but  because  it  acts  on  the  development  of  the 
sex  organs  and  is  of  tremendous  importance  in  determining 
the  reactions  of  the  child  as  expressed  by  its  emotions.  An 
under  activity  of  the  adrenals  is  responsible  for  languor,  tired 
feeling,  asthenia.  It  is  ofttimes  hard  to  determine  whether 
we  are  dealing  with  a  diminution  of  adrenal  secretion  or  a 
diminution  of  thyroid  secretion,  or  a  diminution  of  other 
secretions  in  combinations, — or  whether  one,  two,  three,  or 
more  glands  are  deficient  at  the  same  time.  But  the  adrenal 
function  is  of  the  greatest  importance  at  all  periods  of  life 
and  its  workings  should  be  especially  studied  in  children 
and  in  the  young  because  it  seems  to  be  beyond  the  possibility 
of  doubt,  markedly  related  to  the  emotions  of  anger  and  fear; 
and  of  all  the  detrimental  influences  of  life,  especially  in  the 
life  of  the  child,  the  element  of  fear  plays  the  greatest  part. 

Some  children  are  not  easily  frightened;  others  are  more 
readily  frightened,  and  others  are  of  an  extremely  fearful  or 
fearsome  nature;  and  to  call  these  neurotic  or  psychopathic, 
and  to  say  that  they  have  inherited  these  conditions  may  be 
only  too  true,  but  it  explains  nothing  which  the  parents  can 
understand  and  hope  to  correct ;  nor'  do  these  terms  imply  in 
the  least  that  the  physician  recognizes  that  there  is  something 


PUBERTY   AND    CLIMACTERIUM  163 

wrong  which  may  be  corrected.  The  parents  must  and  should 
do  everything  with  all  children  to  avoid  inculcating  fear,  and 
should  remove  any  element  of  fear  as  much  as  possible  from 
the  mind  of  the  child;  at  this  age  fears,  though  not  remem- 
bered as  having  been  experienced  earlier,  may  persist  as  sensi- 
tive paths  and  continue  throughout  the  whole  life  of  the  affected 
individual. 

The  adrenals  consist  of  two  parts,  the  cortex  and  the 
medulla.  The  medulla, — which  gives  us  adrenalin, — responds 
to  a  stimulus  associated  with  the  emotion  of  fear,  and  the 
medulla  plus  the  cortex  responds  to  the  emotion  of  anger.  It  is 
the  adrenal  cortex  response  which  changes  an  emotion  calcu- 
lated to  be  expressed  by  fear  into  an  emotion  expressed  as 
anger.  Therefore  children  with  a  badly  balanced  adrenal  sys- 
tem, whereby  the  medulla  area  responds  to  stimuli  without  a 
corresponding  response  on  the  part  of  the  cortex,  are  the 
children  who  are  afraid,  fearful,  excitable,  and  nervous.  There- 
fore in  young  children,  slow  growth,  slow  mental  development, 
lack  of  energy,  may  be  dependent  upon  the  failure  of  proper 
activity  on  the  part  of  the  pituitary,  or  the  thyroid,  or  the 
adrenals,  or  upon  a  combination  of  these;  and  the  over-ex- 
citable, nervous,  neurotic,  masturbating,  easily  frightened  chil- 
dren may  have  too  much  stimulation  by  the  thyroid,  too  much 
stimulation  by  the  adrenal  medulla,  or  by  the  post-pituitary,  or 
by  all.  Of  course  the  thymus  and  especially  the  parathyroids 
are  of  the  greatest  importance. 

Among  these  glands  the  thyroid  is  associated  with  the  de- 
velopment of  the  genitalia;  so  is  the  pituitary;  so  are  the 
adrenals ;  and  if  these  glands  which  are  associated  with  the 
development  of  the  genitalia  should  at  any  period  overact  along 
these  lines  the  child  is  unconsciously  affected  and  feels  a  sense 
of  attraction  toward  the  sphere  of  the  organs  which  are  stimu- 
lated. This  is  the  explanation  for  the  slighter  or  greater 
tendency  to  what  are  called  manipulations  by  the  fingers  of; 
the  organs  known  as  the  genitalia.  This  is  frequently  only  a. 
passing  phase,  manifesting  itself  at  different  periods  of  life, 
according  to  the  degree  to  which  the  endocrine  system  is  stimu- 


164  THE    ENDOCRINES 

lating  the  growth  of  these  structures.  It  may  occur  in  the 
early  years ;  it  may  occur  during  the  period  preceding  the  onset 
of  menstruation;  or  it  may  occur  at  any  later  period  of  life. 

The  thymus  gland  has  a  tremendous  effect  on  the  type  of 
the  physical  and  bony  growth  of  the  individual.  It  also  stands 
in  relation  to  the  development  of  the  sex  organs.  Its  physio- 
logical retrogression  takes  place  in  the  early  years,  previous  to 
which  time  it  has  inhibited  too  early  development  of  the  sex 
structures,  and  so  permits  the  sex  organs  to  begin  or  continue 
their  proper  growth.  Hence  the  too  early  removal  of  this 
inhibition  starts  an  early  development  of  the  genitalia,  related 
as  they  are  and  dependent  as  they  are  for  their  trophic  sup- 
port on  the  ovary,  the  pituitary,  the  adrenals,  and  the  thyroid. 
A  too  late  removal  of  the  thymus  from  the  sphere  of  activity 
inhibits  the  development  of  the  genitalia  and  likewise  must 
interfere  with  that  normal  phase  of  the  pituitary,  thyroid,  and 
adrenal  activity  which  is  exerted  on  the  genital  sphere.  In 
conjunction  with  the  thyroid  and  the  other  glands,  the  thymus 
and  the  parathyroids  are  likewise  concerned  with  calcium  and 
bone  metabolism,  and  so  the  type  of  body  form  and  bone  de- 
velopment may  be  markedly  influenced  by  a  persistent  thymus 
action  or  by  too  early  removal  of  same. 

As  the  ovaries  begin  to  show  the  added  secretory  power, 
which  results  eventually  in  menstruation  and  ovulation,  a  rela- 
tively new  secretion,  the  corpus  luteum,  with  added  power  of 
the  interstitial  area  also  is  brought  into  the  circle  of  endocrines, 
and  all  of  them  are  now  concerned  with  the  development  of  the 
body,  mind,  sex  organs  and  sex  functions, — from  puberty, 
through  adolescence,  to  adult  life. 

We  might  imagine  a  family  of,  say  ten,  acting  harmoni- 
ously and  in  concert  for  years.  We  might  then  picture  a  new 
member  introduced  into  this  family  circle.  If  he  fits  in  well 
with  the  other  ten  and  their  relations  are  harmonious,  there 
is  a  peaceful,  contented,  stable  relationship,  since  they  all  act 
in  concert.  But  if  the  new  member  is  noL  in  harmony  with 
the  other,  and  is  arrogant  and  dominant,  an  element  of  irrita- 
tion and  stimulation  is  Introduced  which  will  rouse  and  irritate 


PUBERTY   AND    CLIMACTERIUM  165 

all  the  others ;  or  irritate  some  and  depress  others,  and  there 
is  a  resulting  lack  of  harmony  and  co-ordination. 

So  it  is  with  the  action  of  the  endocrine  chain  at  the 
period  of  puberty  and  on  through  adolescence.  The  more 
stable  and  harmonious  the  activity  and  inter-relation  of  the 
other  endocrines,  the  more  does  the  girl  develop  her  menstrua- 
tion without  annoyances  and  the  more  certainly  does  she  go 
on  through  the  next  succeeding  years  with  little  or  few  un- 
toward manifestations.  The  more  unstable  or  easily  affected 
is  the  endocrine  chain,  the  later  and  more  irregularly  does 
menstruation  develop  with  pain  and  discomfort ;  and  the  more 
are  the  other  glands  over-stimulated  or  under-stimulated,  with 
a  resulting  sense  of  nervousness,  instability,  asthenia,  excitabil- 
ity, and  all  the  other  terms  used  to  describe  the  unfortunate 
'adolescent  young. 

If  there  is  a  marked  hyperthyroidism,  the  girl  will  suffer 
from  tachycardia,  palpitation  of  the  heart,  excitability,  and 
nervousness  at  various  times.  If  there  is  a  hypo-thyroidism, 
the  opposite  is  to  be  expected  and  will  surely  be  noted. 

If  there  is  an  excessive  action  of  the  posterior  pituitary, 
she  will  suffer  from  dysmenorrhoea ;  her  tenderer  emotions  are 
more  easily  aroused,  blushing  is  noticeable,  and  the  sex  feeling, 
— vague  though  it  may  be, — or  the  sex  instinct  is  more  pro- 
nounced.   Psychic  fears  are  more  evident. 

If,  on  the  other  hand,  the  posterior  pituitary  is  under- 
active, there  may  be  no  pain  at  menstruation,  the  menstruation 
may  be  scanty,  and  the  girl  is  liable  to  be  stout  or  adipose, — 
totally  different  in  many  of  her  functions  and  appearance  from 
the  girl  with  posterior  hyperpituitarism. 

If  there  is  a  predominant  stimulation  of  the  adrenal 
medulla,  there  will  be  nen^ousness,  irritability,  sensitiveness, 
blushing,  fear,  anxiety,  etc.  If  the  adrenal  cortex  is  over- 
stimulated,  the  girl  will  show  some  of  the  characteristics  of 
the  male  in  the  way  of  courage,  absence  of  fear,  decided  fond- 
ness for  manly  sports  and,  though  feminine  in  other  ways,  may 
be  less  sentimental. 


166  THE    ENDOCRINES 

All  these  innumerable  variations  of  interglandular  rela- 
tions, and  they  are  almost  limitless,  give  us  such  a  variety  of 
symptoms  and  types  of  girls  that  there  can  no  longer  be  any 
attempt  to  apply  terms  to  any  of  them  except  as  they  apply 
directly  and  specifically  to  each  and  every  individual  viewed 
as  an  independent  entity. 

The  girl  at  school  or  college  with  a  good  thyroid  and  a 
good  anterior  pituitary  is  not  only  studious  and  bright  but 
has  a  more  mature  type  of  mind  and  is  more  settled  than  is 
the  child  with  a  good  thyroid  but  a  poor  anterior  pituitary. 
The  latter  may  be  happy  and  gay  or  excitable,  may  have  ad- 
mirable qualities  in  other  ways,  but  she  lacks  the  studious, 
sedate,  and  settled  character, — the  lack  of  which,  however,  is 
by  no  means  to  be  considered  a  disadvantage  at  this  time. 
And  so  girls  at  the  school  and  college  age  manifest  different 
tastes  and  likings,  varying  emotions,  varying  dispositions,  ac- 
cording to  their  endocrine  make-up;  and  it  is  essential  for 
parents  and  educators  to  understand  these  facts,  for  it  is  abso- 
lutely true  that  while  education,  training,  and  environment 
have  a  most  marked  effect  on  the  emotions,  disposition  and 
character,  the  endocrine  make-up  and  the  endocrine  activity, 
and  the  endocrine  inter-relations  are  the  decisive  factors. 

Therefore  this  period  of  puberty  and  adolescence,  or  rather 
the  entrance  upon  this  stage  of  puberty  is  as  much  a  change  of 
life  for  the  growing  girl,  leading  up  to  and  preparing  her  for 
the  activities  of  the  next  thirty  years,  as  is  what  the  laity  call 
the  "change  of  life"  which  occurs  most  frequently  in  the  late 
forties;  and  the  parallel  between  the  symptoms  at  this  stage 
and  the  symptoms  at  the  later  "change  of  life  period"  is  most 
marked.  But  here  we  are  dealing  with  the  excitation  of  activ- 
ity of  these  glands,  whereas  at  the  climacterium  we  are  deal- 
ing with  the  stage  of  retrogression.  And  very  often,  as  the 
woman  goes  into  this  adolescent  period  peacefully  or  calmly, 
or  upset  and  disturbed,  so  she  may  go  out  of  it  in  the  same 
way. 

It  must  be  remembered,  however;  that  this  would  be  more 
uniformly  true  were  it  not  for  the  innumerable  factors  and 


PUBERTY  AND    CLIMACTERIUM  167 

complications  of  tlie  period  between  adolescence  and  the  true 
change  of  life,— for  here  come  in  the  questions  of  marriage, 
childbirth,  miscarriage,  nursing,  operations,  infectious  diseases, 
fortunate  and  unfortunate  environment,  happiness  or  unhappi- 
ness,  mental  shocks  and  worries,  the  responsibilities  and  cares 
of  motherhood,  all  of  which  contain  vast  possibilities  in  the 
way  of  a  fortunate  or  unfortunate  effect  upon  any  one  of  the 
important  endocrines  or  on  the  whole  system. 

Some  endocrine  chains  are  so  stable  that  none  of  the 
above  mentioned  factors  disturb  them  or  effect  them  perma- 
nently. Other  chains  are  so  sensitive  or  unstable  that  they  are 
more  or  less  profoundly  affected  by  what  often  appears  unim- 
portant. Certain  families  are  characterized  by  marked  stability 
of  endocrine  relationship,  and  in  many  families  one  or  other 
of  the  glands  is  so  dominant  that  it  characterizes  practically 
every  one  of  the  descendants  for  generations,  for  either  good 
or  bad.  Therefore  marked  mentality  and  stability  of  character, 
probity,  and  high  sense  of  morality  characterize  certain  fam- 
ilies for  generations, — nervousness  or  irritability,  or  a  tendency 
to  "neuroses"  and  "psychoses"  and  varying  degrees  of  what 
are  called  emotional  states  may  characterize  other  families. 

If,  for  instance,  the  pituitary  is  the  dominant  gland,  a 
vast  majority  of  the  descendants  for  generations  may  be  of 
tall  or  powerful  stature,  or  of  strong  able  minds, — though 
it  is  to  be  well  understood  that  intermarriage  with  other  en- 
docrine types  is  liable  to  modify  this  type  of  ascendancy.  If 
a  family  is  characterized  by  pituitary  instability,  the  father 
or  mother  may  be  acromegalic  in  body  type  yet  some  of  the 
children  may  show  evidences  of  over-activity  of  the  anterior 
pituitary,  while  others  show  evidences  of  under-activity.  If 
thyroid  instability  is  the  characteristic,  some  of  the  descendants 
will  lean  toward  a  hyperthyroidism  or  various  grades  of  Base- 
dow's disease,  while  others  will  tend  toward  hypo-thyroidism 
or  various  grades  of  myxedema.  Families  characterized  by 
hypersensitiveness  and  overactivity  of  the  posterior  pituitary, 
the  adrenal  medulla  are  likely  to  show  "neurotic"  types  and 
various  grades  of  psychoses  and  neuroses.    Accordingly,  if  we 


168  THE    ENDOCRINES 

could  have  the  photographs  and  the  history  of  our  patients' 
ancestors  we  would  find  every  normal  or  abnormal  state 
dependent  upon  endocrine  activity  to  have  been  inherited, 
though  often  in  forms  apparently  unrelated,  but  actually,  as 
our  knowledge  grows,  due  to  the  same  endocrine  aberrations. 

The  period  of  regression,  at  what  is  known  as  the  climac- 
terium, means  a  rearrangement  of  the  gland  activities,  a  going 
down  hill,  as  it  were,  since  the  function  of  child  bearing  is 
passing.  The  ovary  is  supposed  to  pass  out  of  the  sphere  of 
action  just  as  at  puberty  it  entered  into  a  new  sphere  of  action ; 
and  if  the  other  glands  regress  in  equal  and  parallel  ratio  and 
the  inter-relation  between  the  glands  is  presented,  then  the 
individual  goes  through  this  trying  period  with  few  if  any 
manifestations  of  an  annoying  character.  But  if  the  rearrange- 
ment is  not  a  normal  or  stable  one,  if  some  of  the  endocrines 
regress  more  quickly  than  they  should  and  others  more  slowly 
than  they  should,  or  if  only  the  ovarian  activity  regresses  and 
most  of  the  others  do  not,  we  have  all  the  innumerable  pos- 
sible variations  and  symptoms  due  to  hyper-activity  or  hypo- 
activity,  or  combination  of  hyper  and  hypo,  involving  the  an- 
terior lobe  of  the  pituitary,  the  posterior  lobe  of  the  pituitary, 
the  thyroid  gland,  the  adrenal  cortex,  the  adrenal  medulla,  the 
ovarian  interstitial  gland,  and  the  ovarian  follicular  apparatus. 
Of  all  the  gland  anomalies  at  this  period  overactivity  of  the 
posterior  pituitary  is  productive  of  the  largest  number  of  physi- 
cal and  psychic  abnormalities. 

The  flushes  which  are  associated  with  the  menopause  or 
climacterium  in  many  patients  are  due  to  absence  of  the  secre- 
tion of  the  ovary  which  in  conjunction  with  the  posterior 
pituitary  (for  these  two  glands  are  practically  sisters  in  the 
family)  preserves  a  normal  vasomotor  balance.  If  the  ovaries 
regress  or  are  removed  and  the  post-pituitary  persists  in  its 
former  degree  of  activity  or  its  activity  is  increased,  then  the 
flushes  are  extremely  marked.  If  the  adrenal  medulla  is  over- 
active the  flushes  are  still  worse.  The  administration  of 
ovarian  extract  and  ovarian  residue  therefore  helps  many 
patients  and  cures  some,  but  does  not  cure  all  by  any  means. 


PUBERTY  AND   CLIMACTERIUM  169 

This  is  due  to  the  fact  that  the  pituitary,  freed  of  its  associa- 
tion with  the  ovary,  and  the  adrenal  medulla  are  responsible 
for  the  flashes  or  flushes,  and  unless  to  the  ovary  be  added 
some  gland  extract  which  inhibits  and  holds  the  posterior  pitu- 
itary and  adrenal  medulla  in  check,  only  a  certain  amount  of 
benefit  will  result. 

There  is  a  difference  between  the  term  climacterium  and 
the  term  menopause.  Menopause  means  a  cessation  of  the 
menstruation;  the  climacterium  means  the  period  of  transition 
from  the  most  active  thirty  years  of  a  woman's  life  to  the  sub- 
sequent period  of  peace,  quiet  and  freedom  from  menstruation 
and  its  associated  annoyances.  A  woman  may  be  in  the  climac- 
terium period  and  menstruate  normally  or  even  excessively. 
She  may  therefore  have  some  or  other  of  the  "change  of  life" 
symptorws  long  before  menstruation  ceases,  and  the  annoyances 
may  persist  for  months  or  years  after  the  menopause.  It  is 
most  important  to  recognize  this  all  too  true  state  of  affairs, 
for  only  then  can  a  proper  interpretation  be  made  and  proper 
therapy  instituted.  And  after  the  menopause  and  climacterium 
are  passed  there  are  still  possible  the  various  hyper  and  hypo 
annoyances  involving  the  endocrine  chain,  and  therefore  this  is 
the  period  when  marked  neuroses  and  psychoses  (due  to  the 
endocrines)  may  develop,  just  as  during  the  adolescent  stages 
there  are  various  neuroses  and  some  of  the  psychoses, — the 
most  important  of  the  latter  being  dementia  precox. 

One  all-important  observation  should  not  be  left  out  of 
consideration,  for  it  is  a  most  valuable  aid  to  diagnosis  at  any 
stage  of  the  active  period  of  life, — the  way  the  patient  reacts 
a  few  days  before  each  menstruation.  This  is  a  sign  post 
indicating  which  one  or  more  of  the  glands  is  sensitive  to  over 
or  under  stimulation.  Many  girls  and  women  never  know 
before  each  period  that  they  are  to  menstruate;  others  suffer 
from  physical  pain ;  and  many  suffer  from  nervous  and  psychic 
reactions  of  a  character  unusual  to  them  in  the  inter-menstrual 
period.  A  girl  or  woman  may  be  perfectly  well  for  the  three 
weeks  following  menstruation  and  then  for  a  week,  or  it  may 
be  for  only  a  few  days,  may  be  depressed  or  excited,  irritable 


170  THE    ENDOCRINES 

or  extremely  nervous,  restless,  "crazy,"  as  some  describe  it, 
full  of  restless  energy  at  this  time,  though  calm,  peaceful  or 
even  lazy  at  others.  Here  it  is  our  obligation  and  duty  to  put 
our  finger  on  the  gland  or  glands  which  are  over  or  under 
working,  for  such  symptoms  point  to  an  instability  in  the 
chain,  and  no  physician  should  neglect  to  characterize  these 
symptoms  as  of  the  greatest  importance  not  only  for  the  therapy 
to  be  instituted  but  as  indicating  the  latent  possibilities  for 
subsequent  magnified  upsets  of  this  or  other  glands.  The  one 
thing  which  medical  men,  and  especially  the  gynaecologist  and 
also  the  physician  who  treats  children  and  young  girls,  must  do 
is  to  remove  from  his  vocabulary  the  words  "neurotic,"  "neu- 
rasthenic," and  "hysterical,"  for  they  are  only  cloaks  for  ig- 
norance and  make  a  very  bad  impression  on  the  parents  and 
on  the  child  or  girl  concerned.  -  Practically  all  these  types  cover 
deviations  due  to  the  endocrine  aberrations,  and  if  treatment 
were  instituted  sufficiently  early,  especially  during  childhood, 
and  more  attention  were  paid  to  stimulating  body  and  mental 
growth  by  endocrine  therapy  and  to  correcting  states  of  excit- 
ability, fear,  etc.,  by  the  same  methods,  the  effect  on  the  suc-< 
ceeding  years  of  the  affected  individual's  life  would  be  sol 
markedly  for  the  better  that  I  am  sure  the  future  will  find  us 
astonished  at  the  possibilities  of  such  therapy  during  these 
vital  and  all  important  years. 


CHAPTER  IX 

THE   '-HIGHER   UP"   THEORY   OF    STERILITY    IN 

WO:^IEX  AND  ITS  RELATION  TO  THE 

ENDOCRINES 

The  idea  that  dilatation  and  curettage  represent  the  cor- 
rect, accepted  treatment  for  steriHty  in  women,  remains  fixed 
in  the  minds  of  many  members  of  the  medical  profession, 
probably  furthered  by  the  determined  and  settled  notion  on 
the  part  of  the  laity  that  at  least  this  factor  in  medicine  is 
beyond  controversy.  It  is  unfortunate  that  this  practice 
should  continue,  for  the  harm  that  a  dilatation  and  a  curettage 
may  do  when  an  inflammatory  condition,  often  unrecognized, 
is  present,  needs  no  further  elaboration.  Among  the  sterile 
cases  over  one-fourth  prove  to  have  tubal  and  ovarian  inflam- 
mation. On  the  other  hand,  when  no  inflammation  is  present, 
curettage  seems  ridiculous  when  the  female  is  not  at  fault. 
Patients  are  subjected  to  operative  procedures  without  ade- 
quate preliminary  examination,  for  they  not  infrequently  come 
to  me  after  some  cervicouterine  manipulation,  when  subsequent 
examination  shows  the  male  element  to  be  defective  or  ab- 
sent. If  the  male  side  is  not  at  faulty  curettage  may  have  a 
harmful  and  injurious  influence  on  the  menstrual  function  and 
on  the  ovaries,  since  the  interrelation  between  the  endometrium 
and  the  ovaries,  trophically  considered,  is  in  many  instances 
a  delicate  one  and  resulting  degrees  of  amenorrhea  are  often 
noted. 

The  vagina  and  the  cer^-ix,  because  of  the  ease  of  ap- 
proach, readily  attract  attention  as  the  factors  responsible  for 
the  sterilit}'  and  the  ''higher  up"  points  are  left  totally  out  of 
consideration.  Stress  is  often  laid  on  an  acrid  or  acid  dis- 
charge because  of  its  supposed  injurious  effect  on  the  activity 
of  the  spermatozoa.  I  have  not  been  able  to  verify  this  con- 
tention except  when  it  is  a  part  of  an  inflammatory  condition. 
The  posterior  fornix  is  supposed  in  many  instances  to  be  at 
fault  when  it  does  not  form  the  normal  sac  into  which  the 

171 


172  THE    ENDOCRINES 

cervix  may  dip,  cince,  by  allowing  the  spermatic  fluid  to  run 
out,  the  probability  of  impregnation  is  diminished.  I  have 
learned  to  attach  little  importance  to  this  matter  likewise. 

Quite  another  matter  is  the  question  of  cervical  catarrh. 
In  a  woman  who  has  never  been  pregnant,  a  chronic,  thick, 
yellow,  greenish,  tenacious  cervical  discharge  means  an  ob- 
struction which  no  spermatozoon  may  pass.  If  this  were  the 
only  obstacle  it  might  not  be  so  insurmountable  in  the  course 
of  time,  but  the  inflammation  is  not  situated  in  the  cervix 
alone.  In  other  cases  erosions  are  present  as  a  result  of  in- 
flammations lasting  for  months  or  years  and  in  many  in- 
stances this  inflammation  has  extended  upward  through  the 
endometrium  into  the  tubes  in  varying  degrees.  That  one 
can,  in  many  cases,  by  no  means  definitely  exclude  an  inflam- 
matory tubal  or  ovarian  involvement  goes  without  saying. 
We  find  the  lesions  often  graver  than  diagnosed  by  bimanual 
examination  and  not  rarely  we  find  them  of  a  lesser  degree  of 
severity. 

The  interstitial  area  of  the  tube  may  be  involved  by  in- 
flammation and  the  remainder  of  the  tube  be  normal.  Salpin- 
gitis consequent  on  an  appendix  attack  and  slight  unrecognized 
degrees  of  tuberculosis  must  be  taken  into  consideration.  This 
type  of  case,  where  only  the  inner  area  of  the  tube  is  affected, 
may  remain  sterile  for  varying  periods,  even  for  years.  If 
healed  in  the  course  of  time,  furthered  by  freedom  from  in- 
trauterine manipulation,  it  furnishes  us  with  some  of  the  cases 
of  pregnancy  occurring  after  hope  of  maternity  has  been  aban- 
doned. Gonorrheal  pus  has  been  noted  in  the  tubes  at  opera- 
tion, and  conservative  surgery  has  been  followed  by  uterine 
pregnancy.     (Mrs.  P.) 

To  treat  the  milder  cases,  just  described,  by  dilatation 
and  curettage  is  to  push  the  inflammation  further  out  and  to 
effectually  close  the  outer  ends  of  the  tubes  making  the  sterility 
permanent. 

A  little  light  may  be  thrown  on  one  phase  of  this  ques- 
tion by  considering  the  so-called  one  child  sterility.  After  one 
pregnancy,  whether  It  end  in  labor  (often  with  the  use  of  for- 


THE  "higher  up"  THEORY  OF  STERILITY  IN  WOMEN      173 

ceps),  or  a  miscarriage  or  an  abortion,  or  after  ectopic  gesta- 
tion, no  subsequent  pregnancy  takes  place.  Experience  proves 
that  in  a  large  majority  of  instances,  mild  and  often  unrecog- 
nized tuboovarian  inflammatory  lesions  are  present.  In  addi- 
tion, there  are  instances  of  ovarian  neoplasms  which  preclude 
the  possibility  of  ovulation.  At  the  same  time  abortions  and 
miscarriages  may  result  in  the  formation  of  corpus  luteum 
cysts  or  corpus  luteum  bodies  in  one  ovary  or  the  other,  and 
we  believe  today  that  this  condition  has  an  important  action 
in  inhibiting  ovulation. 

What  part  a  slight  inflammation  plays  in  the  formation 
of  corpus  luteum  cysts  is  not  certain.  The  frequency  with 
which  they  are  found  on  the  right  side  in  young  girls  operated 
on  for  chronic  appendicitis,  makes  the  association  possibly 
that  of  cause  and  effect.  Now,  in  sterility  of  a  primary  nature 
the  same  factors  as  in  one  child  sterility  hold  good,  but  in  ad- 
dition we  must  take  into  consideration  the  question  of  sper- 
matozoa, ova  and  the  supposed  obstruction  offered  by  the 
cervix,  as  well  as  the  various  degrees  of  undevelopment  of 
the  genitalia.  If  examination  shows  normal  spermatozoa  to 
be  present,  the  next  question  is,  Are  normal  ova  present  and 
are  they  given  off  from  the  ovaries?  This  constitutes  an 
important  point  often  decided  only  by  the  history  and  the  sub- 
sequent course  of  events  and  by  exclusion.  If  we  take  it  for 
granted  that  both  spermatozoa  and  ova  are  present,  the  point 
for  us  to  determine  is  the  nature  of  the  trouble  or  the  location 
of  the  obstacle.  It  may  be  the  cervix,  it  may  be  the  tube 
through  failure  of  development,  through  trophic  disturbances 
or  because  of  inflammation.  In  addition  to  the  element  of  ob- 
struction we  must  realize  that  embedding  of  the  fecundated 
ovum  may  fail  to  take  place  because  of  an  abnormal  uterine 
mucosa  or  because  of  lack  of  trophic  stimuli  to  the  endometrium 
or  the  fecundated  ovum  may  be  cast  out  by  the  menstrual 
process  either  before  it  embeds  or  before  attachment  is  secure. 

We  are  now  concerned  with  the  noninflammatory  cases. 
The  cervix  is  readily  examined  by  touch,  observed  with  the 
eye  and  entered  by  the  sound.    It  is  frequently,  and  often  with- 


174  THE    ENDOCRINES 

out  reason,  considered  as  the  obstacle  to  pregnancy  because  the 
external  os  is  narrow,  because  there  is  a  sharp  angle  at  the 
internal  os,  because  the  sound  does  not  enter  the  uterus  or 
does  so  only  after  expert  manipulation.  How  easy  it  is  to  say : 
Here  we  have  the  area  which  must  be  attacked. 

If  we  look  at  the  calibre  of  the  Fallopian  tubes  as  they 
pass  through  the  uterine  cornua  into  the  uterine  cavity,  and 
observe  the  narrow  lumen  through  which  the  spermatozoa  pass 
out  to  join  the  ovum,  and  through  which  the  fecundated  ovum 
passes  on  its  way  to  embedding,  the  element  of  cervical  obstruc- 
tion may  be  seen  in  a  new  light.  My  experience  has  taught 
me  that  if  a  cervix  will  admit  a  sound,  it  will  in  the  vast  ma- 
jority of  cases  offer  a  safe  avenue  of  approach  for  a  spermato- 
zoon ;  and  I  have  come  to  the  conclusion  that  it  takes  a  terribly 
deformed  cervix  to  keep  an  active  spermatozoon  from  climbing 
upward,  and  no  matter  how  large  you  make  the  cervix,  a  dead 
spermatozoon  certainly  cannot  and  an  inactive  spermatozoon 
will  not  find  its  way  upward. 

Fibroids,  by  distorting  the  outline  of  the  uterus  and  the 
shape  and  situation  of  the  tubal  canal,  may  be  a  bar  to  preg- 
nancy. On  the  other  hand,  we  know  many  instances  where 
pregnancy  takes  place  in  spite  of  the  existence  of  fibroids. 
It  is  probably  a  mechanical  question  on  the  one  hand,  mainly 
distortion  of  tubes  especially  at  the  interstitial  area,  and  a 
question  of  the  menstrual  function  on  the  other.  Fibromyo- 
mata  grow  during  pregnancy,  but  in  some  instances  the 
fibromata  do  not  disappear  in  the  stage  of  involution.  This 
leaves  a  uterus  much  distorted  by  single  or  multiple  nodules 
and  is  probably  more  productive  of  one  child  sterility  than  of 
primary  sterility.  If  with  any  fibroid  condition  menstruation 
be  excessive,  that  in  itself  may  prevent  the  embedding  of  an 
ovum.  In  addition  to  which  the  point  must  be  held  in  mind 
that  fibroids  probably  represent  an  excess  of  trophic  control  by 
the  ovaries  and  associated  endocrine  glands,  the  most  im- 
portant among  these  being  the  posterior  pituitary  lobe.  In 
only  a  small  proportion  of  cases  Is  ■  retroflection,  from  a 
mechanical  standpoint,  dissociated  from  anomalies  of  the  en- 


THE  "higher  up"  THEORY  OF  STERILITY  IN  WOMEN      175 

dometrium,  tubes  or  ovaries,  a  bar  to  pregnancy.  That  it  is 
possible  must  however  be  recognized.  As  a  general  proposi- 
tion all  such  uteri  capable  of  replacement,  should  be  held  in 
normal  position  by  the  use  of  the  pessary.  Granted  then  that 
examination  excludes  the  conditions  which  we  readily  under- 
stand to  be  a  bar  to  pregnancy,  and  that  examination  shows 
normal,  active  spermatozoa  to  be  present,  what  do  we  find  when 
we  so  lightly  diagnose  hypoplasia?  So  far  as  menstruation  is 
concerned  we  observe  those  who  menstruate  normally,  a  small 
number  who  menstruate  excessively  and  a  goodly  number  in 
whom  we  note  varying  degrees  of  diminished  menstruation 
at  prolonged  intervals. 

Pregnancy  does  occur  in  patients  who  menstruate  only 
every  two  or  three  months,  even  in  patients  who  menstruate 
only  twice  a  year.  Whether  these  patients  ovulate  without  men- 
struation or  ovulate  only  when  they  do  menstruate,  this  type 
of  menstruation  is  not  an  absolutely  bad  sign  in  the  way  of 
prognosis,  since  endocrine  therapy  often  restores  a  normal 
menstrual  rhythm.  Then  come  the  varying  degrees  of  uterine 
hypoplasia  and  here  too  I  have  learned  to  be  cautious  in  making 
a  prognosis.  A  normal  regular  menstruation  is  encouraging 
even  if  the  uterus  is  small,  but  marked  hypoplasia  with  dimin- 
ished menstruation  offers  the  severest  test.  Then  we  have 
the  opposite  type,  patients  with  large  ovaries  and  normal 
uteri  who  menstruate  profusely.  Here  we  have  to  deal  with  a 
possibility  that  the  ovum  may  be  expelled  very  early,  in  other 
words  it  cannot  embed  because  of  overstimulation  by  the  en- 
docrine glands  concerned  in  menstruation.  It  is  more  than 
theory  that  the  parathyroid,  thyroid,  adrenal  and  pituitary 
glands  share  In  the  premenstrual  and  menstrual  function  and 
are  productive  of  many  of  the  premenstrual  phenomena.     ' 

When  pregnancy  occurs,  enzymes  given  off  by  the 
fecundated  ovum  inhibit  the  processes  leading  to  diapedesis 
and  rhexis  known  as  menstruation.  If  this  process  is  not  in- 
hibited menstruation  takes  place.  This  lack  of  inhibition, 
which  may  be  likened  to  toxin  and  antitoxin,  furnishes  us  with 
that  type  of  case  which  at  occasional  intervals  goes  a  week  or 


176  THE    ENDOCRINES 

ten  days  over  the  expected  period  and  then  menstruates.  There 
is  no  doubt  in  my  mind  that  many  of  these  are  cases  of  fecunda- 
tion where  the  ovum  is  expelled  before  it  has  sufficient  time  to 
be  firmly  grafted.  What  of  those  patients  married  eight,  nine 
or  ten  or  more  years  who  become  pregnant  without  operation, 
without  treatment?  Here  we  must  take  into  consideration  the 
question  of  an  inflammatory  condition,  or  a  dystrophia,  oither 
of  which  was  righted  in  the  course  of  time  by  the  natural  func- 
tions of  the  body.    This  factor  may  likewise  apply  to  the  male. 

Because  such  cases  inspire  us  with  hope,  let  us  adopt  the 
motto  "do  no  harm"  for  those  patients  who  have  never  been 
pregnant,  in  whom  the  cervix  suggests  or  in  whom  the  micro- 
scope confirms  the  existence  of  an  inflammation  in  the  cer- 
vicouterine  canal.  These  patients  should  be  treated  conserva- 
tively with  no  intracervical  manipulation  whatsoever.  We 
consider  these  to  have  some  tubal  inflammation  even  if  not 
recognized  bimanually.  We  are  not  very  hopeful  for  those 
persons  who  previous  to  coming  to  us  have  undergone  some 
operative  procedure  on  the  cervix  or  uterus,  such  as  dilatation, 
curettage,  discision  or  cervical  plastic. 

Let  us  next  approach  the  treatment  in  those  cases  in  whom 
the  use  of  the  microscope,  the  Schultze  tampon,  our  tactile 
sense  and  the  history  exclude  an  inflammation  by  way  of  the 
cervix.  As  an  aside,  let  me  repeat  that  appendicitis  and  tuber- 
culosis may  be  responsible  for  tuboovarian  inflammation.  We 
divide  these  into  three  classes : — Those  who  menstruate  less 
than  is  normal,  those  whose  menstruation  is  normal,  those 
whose  menstruation  is  excessive;  in  any  of  these  instances 
paying  attention  to  the  physical  signs  indicating  ductless  gland 
anomalies,  especially  of  the  ovaries,  the  thyroid  and  pituitary 
glands. 

With  regard  to  these  cases  our  thoughts  are  as  follows 
and  on  this  we  base  our  therapy.  .  .  .  Every  month  one 
ovary  or  the  other  should  give  out  an  ovum.  This  ovum  sup- 
posedly capable  of  fecundation,  is  expelled  into  the  peritoneal 
plasma  and  by  the  wave  action  of  the  ciliated  epithelium  of  one 
tube  or  the  other,  is  attracted  into  the  outer  end,  carried  along 


THE  "higher  up"  THEORY  OF  STERILITY  IN  WOMEN      177 

the  tube  by  the  action  of  the  ciHa  and  then  on  into  the  uterus. 
The  spermatozoa,  if  active,  pass  up  through  the  cervix  and 
uterus  out  into  the  tube  by  their  own  action  against  the  current 
of  the  ciHated  epithehum.  The  union  of  the  spermatozoon 
and  the  ovum  may  take  place  outside  of  the  tube,  in  the  outer 
end  of  the  tube,  in  the  course  of  the  tube  or  in  the  uterus. 

The  fecundated  ovum  embeds  itself  in  the  uterine  mucosa 
as  a  result  of  enzyme  action,  sinking  into  the  decidua  itself 
and  being  almost  covered  by  it.  The  next  expected  menstrua- 
tion fails  to  appear,  because  this  fecundated  ovum  gives  off, 
whether  embedded  within  the  tube  or  in  the  uterus,  hormones 
which  nullify  that  action  of  the  ovaries,  pituitary  and  other 
glands  which  produce  menstruation  at  supposedly  twenty- 
eight  day  intervals. 

If  we  are  dealing  with  a  case  in  which  the  spermatozoa 
are  normal  and  presumably  find  their  way  upward  and  yet  no 
pregnancy  takes  place,  we  are  forced  to  the  conclusion  that 
either  the  ovaries  do  not  give  off  their  ova  or  that  the  ova  are 
not  capable  of  fecundation,  or  that  they  are  not  carried  by  the 
cilia  through  the  tube,  or  that  embedding  does  not  take  place 
or  if  it  does  take  place  it  is  not  a  stable,  permanent  attach- 
ment. It  is  interesting  to  recall  some  of  the  actual  experiences 
which  either  directed  attention  to  the  ovary  or  which  support 
and  verify  the  theory^  that  even  normal  menstruation  does  not 
always  mean  the  liberation  of  ova. 

Case  I. — Tvlrs.  R.  Mai  ried  seven  years  and  sterile.  Oper- 
ated upon  for  sterility  with  a  diagnosis  of  right  salpingo- 
oophoritis.  The  left  tube  was  found  normal,  the  right  closed  at 
the  outer  end,  adherent  appendix.  Partial  resection  of  the  right 
tube  was  done,  a  portion  of  each  \-ery  cystic  ovary  was  resected, 
the  appendix  of  course  removed.  Pregnancy  within  five 
months. 

Case  II. — Mrs.  K.     Married  six  years.     Two  premature 
labors.    Operation  for  secondary  sterility  of  three  years'  dura- 
tion.   Left  dermoid  ovary  removed.     Resection  of  half  of  the 
right  cystic  ovary.    Has  had  one  child,  is  now  pregnant  again. 
Case   III.  —  Mrs.   D.     Married   six   years.      Persistent 


178  THE    ENDOCRINES 

menorrhagia  defying  curettage.  Diagnosis,  oyster  ovaries. 
Half  of  each  very  large,  flat  ovary  resected.  Pregnancy  with- 
in four  months.    Aborted.    Pregnant  soon  after.    Living  baby. 

Case  IV. — Mrs.  M.  Married  three  months.  Acute  retro- 
flexion, prolapsed  cystic  ovaries,  dysmenorrhea.  Glass  stem 
pessary,  suspension  operation,  resection  of  half  of  each  poly- 
cystic ovary.    Subsequent  pregnancy,  normal  delivery. 

Case  V. — Mrs.  C,  Married  two  years.  Cystic  ovaries, 
ovarian  dysmenorrhea.  Resection  of  half  of  each  polycystic 
ovary,  endocrine  therapy,  pregnant. 

Whether  these  patients  became  pregnant  because  of  the 
operation  or  in  spite  of  the  resection  operation  on  the  ovaries, 
must  be  left  to  individual  opinion.  It  must  be  added  that  four 
of  them  were  curetted  and  one  wore  a  glass  stem  pessary  for 
several  months. 

As  regards  the  ovary  then,  these  findings  and  the  patho- 
logical report  suggest  the  following:  The  outer  covering  for 
some  reason,  congenital  or  acquired,  is  found  to  be  firm  and  the 
Graafian  follicles  do  not  break.  Graafian  follicles  may  lack 
that  enzyme  which  is  probably  responsible  for  the  normal 
rupture  of  the  thin  convex  surface,  even  if  the  outer  covering 
of  the  ovary  is  normal.  If  either  of  these  conditions  exist,  un- 
ruptured follicles  remain  in  one  or  other  or  in  both  ovaries. 
In  many  ovaries  there  is  a  tendency  to  the  formation  of  larger 
or  smaller  corpus  luteum  nests  and  of  the  so-called  atresic  folli- 
cles. The  effect  of  these  nests  and  these  atresic  follicles,  gen- 
erally known  as  cystic  ovaries,  is  twofold.  Either  by  mechan- 
ical means  they  prevent  the  ripening  and  thickening  of  the  next 
Graafian  follicle  and  the  exit  of  its  ovum;  or  as  a  result  of  re- 
tention in  the  ovary  of  these  follicle  cysts  or  of  corpus  luteum 
nests,  ovulation  is  inhibited.  Abortion  or  miscarriage  are  fac- 
tors often  responsible  for  the  retention  in  the  ovary  of  corpus 
luteum  bodies  and  of  corpus  luteum  cysts. 

As  regards  the  tubes.  The  tubes  may  be  infantile  in 
character,  there  may  be  congenital  twists,  the  cilia  may  not 
functionate  properly  throughout  the  whole  course  of  the  lumen. 
What  basis  have  we  for  these  conclusions  ?    Repeated  observa- 


THE  "higher  up"  THEORY  OF  STERILITY  IN  WOMEN      179 

tions  of  the  tubes  during  laparotomy  on  patients  who  have 
nursed  for  a  long  period  and  particularly  on  patients  suffering 
from  lactation  atrophy,  have  shown  the  tubes  to  be  so  atro- 
phied, so  poor  in  musculature,  that  they  parallel  absolutely  the 
appearance  observed  in  genuine  hypoplasia  due  to  errors  of 
development.  Though  I  have  made  no  observation  as  to  the 
cilia  in  these  cases,  I  have  adopted  the  view  of  lack  of  function. 

As  regards  the  question  of  failure  of  embedding  and  nest- 
ing, what  co-ordinate  experiences  point  to  the  acceptation  of 
this  view?  It  is  not  necessary  to  quote  the  observations  prov- 
ing the  role  of  the  corpus  luteum  in  aiding  and  furthering 
attachment  of  the  ovum,  and  the  effect  of  early  destruction  of 
corpora  lutea  on  the  continuation  of  pregnancy.  Let  us  deal 
for  a  moment  with  threatened  miscarriage  and  repeated  mis- 
carriages. I  have  for  years  used  thyroid  in  conjunction  with 
arsenic,  mercury  bichloride  and  stypticin  for  both  of  these 
states  with  excellent  results.  I  am  now  using  extract  of  the 
whole  ovary,  thyroid  and  ovarian  residue  with  an  occasional 
dose  of  morphine  for  threatened  msicarriage  and  the  same 
preparation  without  morphine  for  repeated  miscarriage,  no 
longer  paying  exclusive  attention  to  the  Wassermann  side  of 
the  question.  The  results  are  so  excellent  in  both  these  con- 
ditions that  I  consider  them  the  best  test  and  the  best  proofs 
of  endocrine  therapy  in  the  whole  realm  of  gynecology. 

It  is  only  a  slight  step  from  this  experience  to  the  con- 
clusion that  if  these  gland  extracts  aid  in  preserving  the  con- 
tact of  the  ovum  and  its  continued  growth,  that  they  must  of 
necessity  have  the  same  power  in  promoting  embedding  of 
many  a  fecundated  ovum  which  without  this  aid  is  cast  off  at 
menstruation.  If  these  considerations  concerning  ovary,  tube 
and  decidua  be  true,  the  way  to  treat  these  conditions  is  clearly 
pointed  out  to  us.  We  must  substitute  those  internal  secretions 
which  are  lacking  or  we  must  excite  the  action  of  certain  of 
those  internal  secretions  in  order  to  cause  the  rupture  of  a 
Graafian  follicle  containing  a  ripe  ovum ;  to  give  power  to  the 
Graafian  follicle  to  secrete  an  enzyme  which  will  enable  it  to 
rupture;  to  stimulate  the  lining  of  the  tubes  so  that  the  cilia 


180  THE    ENDOCRINES 

will  function  and  to  exert  a  trophic  action  on  the  endometrium 
which  will  permit  the  embedding  and  retention  of  a  fecundated 
ovum.  In  other  words  we  stimulate  by  extracts  of  the  glands 
which  normally  preside  over  those  functions.  On  the  other 
hand  if  the  action  of  the  ovaries  and  associated  supporting 
glands  be  increased,  and  the  patient  menstruates  too  often  or 
too  profusely,  then  we  are  dealing  with  endocrines  unusually 
assertive  or  a  uterus  too  greatly  stimulated.  Here  we  must 
inhibit  these  stimuli  and  diminish  menstrual  function  by  en- 
docrines or  by  resection  of  part  of  each  ovary. 

Although  the  usual  treatment  of  sterility  as  I  now  prac- 
tice it  consists  mainly  of  two  preparations  of  ovarian  extract 
and  one  of  thyroid,  let  me  make  mention  of  a  few  general 
considerations.  We  prescribe  according  to  the  patient's  local 
signs,  menstrual  symptoms  and  constitutional  make-up.  We 
judge  from  a  patient's  appearance,  her  weight,  the  distribution 
of  hair,  character  of  the  skin,  cold,  clammy  hands,  premen- 
strual phenomena,  rate  of  the  pulse,  blood  pressure,  as  well  as 
of  our  local  findings.  Now  the  glands  which  stimulate  genital 
function  are  ovarian  secretion  itself,  thyroid  secretion,  supra- 
renal extract,  pituitary  gland  posterior,  in  some  cases  prob- 
ably anterior.  The  glands  which  serve  to  diminish  the  men- 
strual function  are  thymus  and  mammary,  placental  extract, 
and  in  some  phases  probably  thyroid. 

When  a  patient  shows  signs  of  myxedema  or  myxedema 
of  the  endometrium  is  suspected,  thyroid  is  indicated.  If  pa- 
tients show  signs  of  hyperthyroidism  or  exopthalmic  goitre, 
thyroid  is  not  indicated.  Patients  having  a  typical  dystrophia 
adiposo  genitalis  are  the  victims  of  a  pluriglandular  condition. 
To  such  patients  we  give  pituitary  extract  in  addition  to  ovary 
and  thyroid.  Patients  with  low  blood  pressure  and  asthenia 
suggest  the  administration  of  suprarenal  extract  and  pituitary 
extract.  Patients  with  large  uteri  and  excessive  menstruation, 
patients  with  large  ovaries  and  excessive  menstruation,  whether 
these  ovaries  appear  cystic  or  not,  the  so-called  oyster  ovary, 
suggests  the  administration  of  thymus  or  mammary  extract 
or  placental  extracts  or  all  three. 


THE  "higher  up"  THEORY  OF  STERILITY  IN  WOMEN      181 

In  a  series  of  fifty  consecutive  private  cases  of  primary- 
sterility,  i.  e.,  patients  whose  query  was  "Why  do  I  not  become 
pregnant?"  I  found  that  twelve  had  marked  inflammatory 
lesions  of  the  annexa,  while  two  had  ovarian  neoplasms  which 
did  not  permit  of  ovulation.  Of  these  fourteen  patients  nine 
were  laparotomized  and  the  diagnosis  confirmed.  In  fourteen 
cases  the  sterility  was  due  to  the  male,  the  spermatozoa  being 
either  absent  or  markedly  defective  in  number  and  motility. 
In  ten  patients  where  examination  of  the  male  disclosed  normal 
spermatozoa,  no  pregnancy  has  resulted  in  spite  of  endocrine 
therapy.  Of  these  ten  patients  only  two  had  a  normal  men- 
struation. One  of  these  two  had  been  curetted  and  has  a  sensi- 
tive cystic  ovary.  The  other  eight  of  these  ten  unsuccessful 
cases  are  patients  with  irregular  and  markedly  diminished  men- 
struation, two  of  them  being  well  marked  examples  of  dystro- 
phia adiposo  genitalis.  The  menstruation  in  ever}'-  case  but  one 
was  improved  by  endocrine  therapy  and  this  patient,  who  men- 
sturates  only  twice  a  year,  discontinued  the  endocrines  after 
a  few  weeks.  (One  of  the  ten  has  conceived  since  the  com- 
pilation of  these  reports.)  Twelve  patients  have  responded 
to  endocrine  therapy,  eleven  having  become  pregnant  within 
three  months  after  administering  the  gland  extract  and  one 
after  this  therapy  was  continued  for  months.  In  these  twelve 
successful  cases  menstruation  was  irregular  and  below  the 
normal  amount  in  six  cases  and  excessive  in  one  case. 

If  we  have  succeeded  in  these  twelve  cases  without  dila- 
tation, curettage  or  operations  upon  the  cervix,  that  certainly 
excluded  them  from  the  category  of  cervical  stenosis  or  cervical 
obstruction.  The  complete  test  would  be  to  perform  partial 
ovarian  resections  in  the  cases  which  have  resisted  endocrine 
therapy.  The  fact  that  most  of  them  have  relative  amenorrhea 
makes  me  loath  to  make  the  attempt.  I  believe  cases  of  normal 
or  excessive  menstruation  to  be  the  only  ones  favorable  to  ab- 
dominal interference.     (See  cases  quoted  above). 

Endocrine  stimulating  therapy  is  the  only  rational  sug- 
gestion in  the  different  degrees  of  hypoplasia  with  relative 
amenorrhea.     Here  curettage  is  contraindicated.     A  stem  pes- 


182  THE    ENDOCRINES 

sary  retained  in  the  cervix  for  months  has  much  to  commend 
it.  Through  auto  massage  and  rhythmic  contractions  and 
through  the  associated  trophic  action  on  the  ovaries,  benefit 
might  be  hoped  for,  but  the  possibility  of  furthering  some  form 
of  infection  cannot  be  denied. 

It  may  be  granted  that  some  of  these  patients  might  have 
become  pregnant  without  endocrine  therapy.  Witness  the  case 
of  Mrs.  H.  whose  menstruation  was  excessive  and  who  after 
taking  thymus  extract  for  two  weeks  passed  her  next  menstrua- 
tion and  continued  with  her  pregnancy.  Also  the  case  of  Mrs. 
B.  married  one  year  who  after  taking  ovarian  extract  and  thy- 
roid for  three  weeks  likewise  passed  her  next  menstrual  period 
and  continued  with  her  pregnancy.  Of  the  successful  cases  the 
majority  have  responded  within  three  months,  which  points  to 
the  stimulation  of  embedding  and  nesting  as  a  very  probable 
factor.  This  much  is  to  be  said  for  the  endocrine  therapy  of 
sterility  that  it  should  be  tried  as  a  routine  method  in  the 
promising  cases  before  any  operative  procedure  is  attempted. 

My  purpose  is  not  to  decry  the  value  of  a  curettage  when 
dealing  with  cervical  or  uterine  adenoids.  We  cannot  wholly 
deny  the  possible  value  of  a  cervical  dilatation  or  plastic.  We 
cannot  deny  the  value  of  correcting  a  retroflexion  by  pessary 
or  operation.  Our  purpose  is  to  banish  routine  indiscriminate 
cervical  and  uterine  procedures  as  the  first  thought,  and  to 
concentrate  our  attention  primarily  on  the  areas  higher  up 
and  thus  eventually  diagnose  abnormalities  and  trophic  changes 
which  are  in  most  cases  the  cause  of  sterility  in  woman,  if  the 
fault  is  the  woman's.  So  I  have  come  to  this  conclusion: 
Those  cases  of  sterility  with  normal  spermatozoa  in  the  part- 
ner which  after  thorough  examination  show  no  inflammatory 
lesions,  which  menstruate  normally  or  excessively,  which  do 
not  yield  to  endocrine  therapy,  are  legitimate  promising  cases 
for  operation.  Whether  that  operation  be  cervicouterlne,  or 
abdominal,  or  both,  will  depend  on  the  faith  one  has  in  the  idea 
that  "cystic  ovaries"  and  the  endocrines  do  bear  a  relation  to 
pregnancy  and  to  sterility.  On  the  Other  hand  we  must  not 
confine  our  attention  only  to  the  female.    There  are  cases  where 


THE  "higher  up"  THEORY  OF  STERILITY  IN  WOMEN      183 

spermatozoa  are  present;  they  are  inactive  or  they  are  active 
but  not  normal.  We  attempt  the  same  stimulation  by  gland 
extracts.  We  give  here  testicular  extract,  thyroid  extract, 
pituitary  extract,  suprarenal,  etc. 

Sterility 

Therapy  aids  us  in  proving  a  theory.  If,  for  instance,  any 
one  gland  extract  or  a  combination  of  gland  extracts  without 
any  other  treatment  cures  a  case  of  sterility,  it  may  be  a  co- 
incidence; in  fact  the  patient  might  have  been  pregnant  at 
the  time  of  examination.  If  two  or  three  or  four  other  ap- 
parently normal  but  sterile  patients,  under  the  administra- 
tion of  any  of  the  indicated  gland  extracts  or  a  combination 
of  extracts,  without  the  aid  of  any  other  treatment,  become 
pregnant  within  two  to  twelve  weeks,  it  is  suggestive.  If  a 
dozen  sterile  patients  conceive  under  the  same  form  of  therapy, 
it  is  probable  that  the  prescribed  endocrines  have  caused 
changes  of  a  trophic  or  allied  nature  which  have  resulted  either 
in  ovulation,  fecundation,  or  nidation  where  one  or  the  other 
has  not  occurred  before.  If  thirty  cases  are  successfully  treated 
in  the  same  manner,  granted  that  there  are  failures,  the  reason 
for  which  can  be  satisfactorily  given  in  most  instances  but  not 
in  all,  we  must  conclude  that  the  physician  is  justified  in  pro- 
claiming the  fact  that  endocrine  therapy  is  valuable  in  the 
treatment  of  sterility.  And  here,  in  order  to  be  explicit  and 
clear  and  to  leave  no  room  for  possible  misunderstanding,  it 
must  be  understood,  as  all  reasonable  medical  men  would 
naturally  understand,  that  the  curable  cases  are  those  where 
normal  spermatozoa  are  present  in  the  partner,  where  there 
is  no  double  pysosalpinx  or  salpingitis  or  closed  tubal  ends, 
where  there  are  no  bilateral  dermoids  or  ovarian  tumors  and 
where  the  uterus  is  of  a  size  sufficiently  approaching  the  normal 
to  lead  any  reasoning  examiner  to  understand  that  it  might 
conceivably  serve  as  the  nest  for  an  embedded  and  growing 
ovum. 

These  are  of  course  the  grosser  and  easily  recognized  ob- 
stacles to  sterility  but  they  have  their  finer  and  not  so  easily 


184  THE    ENDOCRINES 

demonstrated  or  recognized  minor  degrees  of  abnormality, 
such  as  completely  cystic  ovaries,  or  chronic  inflammatory,  and 
often  gonorrheal,  mucoid  discharge  from  the  cervix.  Prac- 
tically all  cases,  except  such  as  are  above  mentioned,  come 
into  the  realm  of  curable  sterility. 

A  patient  who  had  been  married  four  months  and  whose 
previous  menstruation  varied  in  period  between  one  and  six 
months  consulted  a  gynecologist,  who  performed  a  cervical 
plastic  operation.  A  few  months  later  she  consulted  another 
gynecologist,  who  curetted  her.  When  she  came  to  me  her 
amenorrhea  had  lasted  nine  months.  Examination  showed 
complete  atresia  of  the  cervix  which  I  corrected  at  operation 
and  a  cervical  stem  was  introduced  after  a  thorough  irriga- 
tion of  the  uterus.  It  is  not  easy  to  understand  why  either 
of  the  previous  procedures  (cervical  plastic  or  curettage)  was 
attempted  for  the  correction  of  sterility  in  a  patient  with  such 
a  menstrual  history. 

Each  year  I  see  several  patients  in  whom  a  curettage  has 
been  followed  by  either  a  relative  or  a  complete  amenorrhea. 
There  is  beyond  doubt  an  intimate  relation  between  the  ovary 
and  the  endometrium.  The  endometrium  grows  thicker,  the 
cells  enlarge,  the  capillaries  dilate  for  from  seven  to  ten 
days  before  each  expected  menstruation,  this  decidua  men- 
strualis  forming  an  appropriate  nesting  structure  for  a  fecun- 
dated ovum.  As  the  endometrium  undergoes  these  changes 
through  the  stimulation  produced  by  the  secretion  or  secre- 
tions of  the  ovaries  aided  by  other  glands  which  exert  a  trophic 
influence  on  the  ovaries  and  uterus,  a  reaction  is  exerted  by 
the  secretion  of  the  endometrium  upon  the  ovaries  and  this 
reciprocal  influence  is  of  importance. 

If  the  uterine  lining  be  curetted  away  too  thoroughly, 
especially  in  what  might  be  called  a  sensitive  case,  the  re- 
action on  the  ovaries  can  be  appreciated,  and  the  untoward 
results  just  called  to  mind  speak  for  themselves. 

The  normal  endometrium  is  not  a  mucous  membrane 
to  be  removed  without  reason.  The  curette  has  its  place,  and 
well  does  it  serve  us  in  properly  selected  instances.     When  the 


THE  "higher  up''  THEORY  OF  STERILITY  IN  WOMEN      185 

endometrium  is  overgrown  or  polypoid,  if  uterine  polypus  or 
cervical  polypus  be  present,  if  in  a  miscarriage  all  the  tissues 
of  the  ovum  are  not  cast  out,  if  we  suspect  a  malignant  change 
in  the  endometrium,  a  curative  or  diagnostic  curettage  is  in- 
dicated. 

Certain  cases  of  menorrhagia  without  appreciable  change 
in  the  endometrium,  certain  other  cases  to  which  the  name 
fibrosis  uteri  may  be  given,  certain  cases  of  fibroid  of  the 
uterus,  respond  splendidly  to  a  curettage,  especially  if  fol- 
lowed by  the  administration  of  ergot  or  ergotole  or  mammary- 
extract,  or  by  hypodermics  of  ernutin  or  aseptic  ergot. 

Is  there  any  other  danger  than  a  resulting  amenorrhea 
which  can  be  mentioned  or  blamed  on  a  curettage?  The  ele- 
ment which  always  makes  me  fearful  is  the  possibility  of  an 
unrecognized  inflammation. 

Speaking  now  of  women  who  have  never  borne  children 
or  who  have  not  miscarried,  a  chronic  discharge  of  greenish- 
yellowish,  tenacious  mucus  from  the  cervix  constitutes  a  warn- 
ing. It  is  an  evidence  not  of  a  hypersecretion  but  of  an  in- 
flammation against  which  the  cervix  is  battling  by  the  pro- 
duction of  mucus.  An  Infection  may  extend  up  through  the 
cervix  and  uterus  into  the  tubes,  ovaries,  and  peritoneum ;  and 
the  cervix  may  react  by  no  mucoid  discharge.  On  the  other 
hand,  in  many  cases  there  is  an  attempt  on  the  part  of  nature 
to  fight  the  invading  bacteria  and  thus  limit  the  upward  spread 
of  the  infection.  AVhy  some  patients  respond  by  this  mucoid 
means  of  defense  and  others  do  not,  is  a  matter  evidently  de- 
pendent on  many  considerations  belonging  more  or  less  to  the 
question  of  Immunity.  Such  cases  are  never  dilated  nor 
curetted  by  me,  and  for  two  reasons :  ( 1 )  It  Is  almost  impos- 
sible to  cure  this  cervical  discharge  unless  the  entire  cervdcal 
mucous  membrane  Is  removed,  for  so  long  as  the  deeply  end- 
ing glands  are  presented  the  mucosa  will  be  restored  and  the 
infection  still  remaining  In  these  crypts  and  In  the  connective 
tissue  outside  of  them  will  continue  to  produce  the  discharge. 
(2)  But  a  second  and  more  Important  reason  Is  our  Inability 
to  determine.  In  all  cases,  how  high  the  Infection  has  spread; 


186  THE    ENDOCRINES 

and  any  curetting-  of  the  endometrium  is  of  course  contra- 
indicated  whenever  an  infection,  latent  or  active,  is  present 
in  the  tubes  and  in  the  endometrium. 

Leaving  aside,  however,  these  cases  with  this  pronounced 
cervical  discharge,  there  are  only  too  many  where  an  infection 
has  spread  upward,  leaving  in  the  cervix  few  if  any  evi- 
dences. It  is  only  when  we  collect  on  a  cotton  tampon  placed 
around  the  cervix  the  secretion  of  the  cervix  and  uterus  for  a 
period  of  twenty-four  hours,  and  subsequently  examine  this 
discharge  under  the  microscope,  that  we  can  with  any  certainty 
express  an  opinion  on  this  all-important  question.  One  has 
only  to  see  a  case  of  early  gonorrheal  infection  respond  favor- 
ably to  conservative  treatment — consisting  at  first  of  douches 
— to  note  how  within  a  few  months  or  perhaps  even  a  few 
weeks,  all  signs  of  the  original  vulvar,  vaginal,  or  cervical  in- 
volvement have  disappeared ;  and  it  would  be  a  bold  man  who 
could  express  an  authoritative  opinion  on  the  areas  further  up 
without  the  just  mentioned  method  of  examination.  It  is  by 
collecting  the  secretion  discharged  upon  this  cotton  tampon 
from  the  cervix  and  uterus  over  a  period  of  twenty-four  hours, 
and  examining  it  under  a  microscope,  that  we  remark  how 
often  a  smear  of  pure  pus  cells  is  obtained;  and  if,  after  a 
period  of  months  or  years  the  cervical  uterine  discharge  is 
negative,  we  still  may  have  to  deal  with  a  latent  inflammatory 
condition  in  the  tubes. 

It  is  only  by  comparing  one's  diagnoses  with  the  findings 
during  laparotomy  that  one  visualizes  the  frequency  with  which 
salpingitis  and  cobweb  adhesions  escape  the  tactile  sense. 
Therefore  a  dilatation  and  curettage  may  be  productive  of 
great  harm  if  an  unrecognized  inflammation  or  a  condition 
not  correctly  viewed  as  an  Inflammation  is  present. 

The  all-important  point  of  spermatozoa  frequently  re- 
ceives no  consideration.  Often  enough  have  I  observed  pa- 
tients who  came  to  me  because  of  sterility  and  who  had  been 
curetted — some  of  them  twice  and  even  three  times — when 
my  subsequent  examination  of  the  partner  showed  the  sperma- 


THE  "higher  up"  THEORY  OF  STERILITY  IN  WOMEN      187 

tozoa  to  be  absent  or  to  be  present  few  in  number,  non-motile 
or  only  slightly  active. 

The  element  of  hypoplasia  or  atrophy  of  the  uterus  and 
ovaries  is  of  the  greatest  importance,  and  the  greater  the 
degree  of  relative  amenorrhea,  the  less  favorable  as  a  rule  is 
the  prognosis.  I  am  almost  inclined  to  the  belief  that  a  men- 
struation every  six  or  ten  weeks,  associated  with  a  normal 
loss  of  blood,  is  of  no  worse  prognostic  significance  than  a 
regular  menstruation  of  only  a  day  or  so;  but  it  is  as  unsafe 
to  state  that  such  patients  do  not  ovulate  as  it  is  to  state  that 
all  women  who  menstruate  normally  do  ovulate;  for  here 
again  our  experience  during  operations  shows  that  many  pa- 
tients, in  spite  of  regular  menstruation,  do  not  ovulate.  The 
structure  of  the  outer  covering  of  the  ovary  may  be  so  altered 
that  Graafian  follicles  do  not  burst.  Circulatory  changes,  fre- 
quently prompted  by  displacements,  may  have  a  like  effect. 
The  liquor  folliculi  bursts  through  the  thin  covering  of  the 
follicle  and  carries  with  it  the  ovum.  But  this  bursting  cannot 
be  dependent  simply  on  pressure;  there  must  be  in  the  liquor 
folliculi  an  enzyme  or  ferment  which  assists  in  this  process. 
If  because  of  any  of  these  conditions  the  follicles  do  not  rup- 
ture, the  ovaries  become  filled  with  follicle  cysts  and  these,  to- 
gether with  corpus  luteum  rests,  because  of  their  presence, 
add  to  the  difficulty  of  subsequent  ovulation. 

The  cases  of  sterility  favorable  for  treatment  of  any  sort 
are  those  in  which  no  evidence  of  inflammation  can  be  found, 
those  in  which  the  hypoplasia  is  of  no  marked  degree,  and  those 
only  where  spermatozoa  in  the  male  are  found  to  be  normal. 

What  is  the  treatment  for  these  cases  ? 

Heretofore,  and  even  now,  with  many  the  favored  plan 
is  a  dilatation  with  or  without  a  curettage,  or  some  form  of 
cervical  discission  or  plastic.  This  denotes  that  those  who 
practise  these  methods  exclusively  believe  the  mechanical  ob- 
stacle of  the  cervix  and  its  canal  to  be  the  one  and  important 
factor.  I  do  not  hold  to  this  opinion  nor  have  I  held  this  view 
for  many,  many  years.  A  cervix  which  will  admit  a  sound, 
which  is  not  filled  with  overgrown  endometrium,  is  rarely  a 


188  THE    ENDOCRINES 

bar  to  the  upward  movement  of  the  microscopic  spermatozoa. 
Besides,  as  I  have  frequently  stated,  the  interstitial  area  of  the 
tube  is  infinitely  smaller  in  caliber  than  the  cervix,  and  yet  the 
ovum  is  passed  through  it  into  the  uterus  and  the  spermatozoa 
pass  out  through  it  into  the  tube. 

My  explanation  as  to  the  causation  of  sterility  in  the 
so-called  favorable  cases  fixes  the  blame  either  on  the  ovaries 
and  the  failure  of  ovulation,  or  on  the  tube  and  its  cilia  which 
are  to  move  the  ovum  into  the  uterus,  or  on  the  uterine  lining 
which  is  the  ground  in  which  the  ovum  is  to  nest,  or  on  the 
inability  of  the  fecundated  ovum  to  inhibit  menstruation. 

If  a  patient  pregnant  eight  weeks  or  more  menstruates 
and  casts  out  the  ovum  with  its  chorionic  villi,  we  call  it  mis- 
carriage, but  if  the  fecundated  microscopic  ovum,  without  villi, 
is  cast  out  when  a  patient  is  only  a  few  days  over  her  men- 
struation, we  are  in  no  position  to  be  certain  that  this  has  been 
the  case,  yet  in  all  probability  it  occurs  often  enough. 

The  most  interesting  phase  of  pregnancy  is  the  amenor- 
rhea. Why  does  menstruation  fail  to  take  place  when  a  tiny 
fecundated  ovum  settles  in  the  uterus,  or  occasionally  in  the 
tube? 

Menstruation  is  the  loss  of  blood  poured  out  from  the 
capillaries  and  vessels  of  the  endometrium  when  no  pregnancy 
has  taken  place.  The  endometrium,  like  a  wet  sponge,  is  re- 
lieved of  its  engorgement  and  returns  in  a  few  days  to  its  nor- 
mal thickness.  No  lining  has  been  lost,  only  a  few  epithelial 
cells.  Under  the  stimulation  exerted  primarily  by  the  ovaries 
and  possibly  accentuated  by  a  remaining  ruptured  follicle,  the 
endometrium  prepares  itself  again  in  the  form  of  a  decidua 
menstrualis  for  a  fecundated  ovum.  When  such  a  fecundated 
ovum  enters  the  uterus  and  nests  itself  beneath  the  surface  it 
does  show  a  growth  of  cells  on  its  outer  covering;  these  cells 
do  penetrate  into  the  surrounding  tissue  and  capillaries,  but 
menstruation  does  not  take  place.  It  is  too  much  to  say  that 
a  certain  reflex  stimulation  has  inhibited  menstruation;  the 
only  available  explanation  is  that  the  cells  of  the  outer  cover- 
ing, entering  as  they  do  the  maternal  circulation — those  cells 


THE  "higher  up"  THEORY  OF  STERILITY  IN  WOMEN      189 

which  form  the  future  chorion  and  placenta — by  their  action 
as  a  hormone,  hold  off  the  menstrual  flow. 

Menstruation  is  dependent  on  the  normal  action  of  the 
ovaries  and  their  secretion.  If  the  ovaries  are  removed,  no 
gland  extract  that  we  can  give  will  restore  it;  therefore  the 
ovaries  supply  hormones  and  are  aided  by  other  hormones 
which  we  cannot  yet  supply  to  the  body  in  efficient  character 
or  sufficient  or  proper  quality.  The  ovaries  are  not  essential 
to  life.  When  removed,  in  spite  of  the  flushes  and  other  annoy- 
ances, duplicated  in  many  instances  at  the  normal  climacterium, 
the  patient's  physical  health  is  not  seriously  affected.  These 
flushes  are  due  not  only  to  absence  of  ovarian  secretion  but 
to  a  hyperactivity  of  the  posterior  pituitary.  The  ovaries  are 
of  the  greatest  importance,  however,  because  they  normally 
furnish  each  month,  in  supposedly  ripe  form,  at  least  one  of 
the  twenty-five  or  thirty  thousand  ova  which  they  contain ;  but 
of  all  the  structures  of  the  body  which  have  a  secretory  func- 
tion the  ovary  is  the  weakest  in  that  its  activity,  as  well  as  its 
development,  is  dependent  on  a  proper  trophic  support  by  other 
glands;  and  this  trophic  support  is  quite  as  essential  for  the 
tubes  and  uterus  as  for  the  ovaries. 

Pathology  has  taught  us  how  profoundly  the  growth 
of  the  body  may  be  held  in  check  or  stimulated  or  altered  by 
the  overactivity  or  underactivity  of  the  pituitary  gland,  the  thy- 
mus, the  thyroid,  the  adrenals,  etc.,  and  it  teaches  the  gyne- 
cologist how  profoundly  the  genital  tract  is  involved  by  disease 
of  these  same  glands.  An  underactivity  of  the  pituitary  most 
profoundly  affects  the  development  of  the  ovaries  and  the 
uterus ;  but  if  posterior  pituitary  inactivity  takes  place  after 
their  development,  it  may  bring  about  their  atrophy.  Affec- 
tions of  the  thyroid  gland  play  an  important  part.  Aside 
from  these  changes,  the  genital  tract  miay  be  injured  by  the 
infectious  diseases  of  childhood  or  by  subsequent  constitu- 
tional diseases  (leaving  displacements  and  inflammations 
aside). 

Now  menstruation,  initiated  as  it  is  by  the  ovaries  and 
preceded  as  it  is  in  normal  cases  by  the  exit  of  an  ovum,  is  not 


190  THE    ENDOCRINES 

a  local  process  only.  It  is  a  constitutional  involvement  not 
experienced  disagreeably  by  many  women  but  associated  in 
very  many  instances  with  what  are  known  as  premenstrual 
phenomena;  and  these  premenstrual  phenomena  are, due  not 
only  to  the  changes  produced  in  the  body  by  the  cumulative 
action  of  the  ovarian  secretion,  but  to  the  associated  altered 
activities  of  the  thyroid,  the  adrenals,  and  the  pituitary  gland, 
especially  the  posterior  lobe.  The  general  symptoms  of  this 
recurring  premenstrual  period  always  show  which  of  the  en- 
docrines  is  or  are  stimulated  or  inhibited  and  thus  the  unstable 
member  or  members  of  the  chain  are  disclosed.  So  we  may 
say  that  the  trophic  support  of  the  genitalia — of  the  uterus  in 
particular — is  dependent,  not  only  on  the  ovary  itself,  but  on 
the  thyroid,  adrenals  and  pituitary  likewise.  Here  we  must 
not  forget  the  action  of  the  adrenal  glands.  If  we  are  to 
initiate  a  glandular  or  endocrine  therapy  for  sterility,  we  have 
only  to  point  back  to  the  role  which  pathology,  if  nothing  else, 
has  taught  us ;  for  tumors  of  the  pineal  gland,  of  the  pituitary, 
of  the  adrenals,  etc.,  have  frequently  enough  been  found  to 
have  a  marked  influence  on  growth  and  sex  development. 
Acromegaly,  myxedema,  the  dystrophias,  the  rarer  cases  of 
Addison's  disease,  etc.,  have  their  decided  role  in  afifecting 
the  functions  of  the  ovary  and  of  the  uterus,  and  the  same 
holds  true  of  the  like  diseases  of  lesser  degree. 

Now,  coming  back  to  the  question  of  sterility  itself;  I 
doubt  whether  in  the  last  ten  years  I  have  dilated,  curetted, 
or  done  a  cervical  plastic  (except  for  intractable  dysmenorrhea) 
in  five  per  cent,  of  the  cases  of  sterility  which  I  have  viewed  as 
curable.  By  curable  I  refer  to  cases  where  the  husbands  have 
normal  spermatozoa,  where  tuboovarian,  inflammatory,  and 
tumor  conditions  were  absent ;  and  where  the  menstruation  was 
normal,  or  if  deficient,  was  not  associated  with  a  marked  poly- 
glandular anomaly  of  a  type  as  severe  as  a  well-developed  dys- 
trophia adiposogenitalis.  Among  these  cases,  the  vast  ma- 
jority fell  into  the  class  of  relative  uterine  hypoplasia.  The 
whole  plan  of  treatment  was  dominated  by  (1)  the  notion  of 
trophic  stimulation  of  the  "genital  tract  in  those  cases  where 


THE  "higher  up"  THEORY  OF  STERILITY  IN  WOMEN      191 

the  theory  of  substitution  impHed  a  lack  of  autostimulation 
by  the  patient's  own  endocrines;  (2)  the  theory  of  inhibition 
in  a  smaller  proportion  of  cases  where  menstruation  was  ex- 
cessive; (3)  the  theory  of  stimulation  and  inhibition  where 
uterine  contractions  with  or  without  excessive  menstruation 
might  be  presumed  to  expel  an  ovum  a  few  days  after  fecunda- 
tion and  attempted  nidation,  especially  if  nidation  occurred 
shortly  before  the  menstrual  period. 

I  found  that  in  a  certain  proportion  of  cases  the  patients, 
during  one,  two,  or  three  periods  of  the  year,  went  a  week  or 
ten  days  over  menstruation,  but  at  other  times  menstruated  to 
the  day;  and  in  this  type  of  cases  the  results  of  endocrine  treat- 
ment have  been  so  uniformly  good  that  I  was  forced  to  the 
conclusion  that  the  menstrual  wave  often  throws  out  the  ovum 
before  the  nesting  is  completed  or  fixed.  There  is  during  preg- 
nancy a  recurrence  of  the  menstrual  wave  at  regular  periods. 
It  is  painless,  not  recognized  in  the  vast  majority  of  instances, 
and  is  associated  with  minor  degrees  of  molimina  in  others. 

Some  pregnant  patients  have  periodical  headaches ;  others 
have  an  occasional  spotting  of  blood  at  intervals  corresponding 
to  the  menstrual  period ;  others  bleed  more  noticeably  Now, 
others  go  through  the  experience  of  expelling  an  ovum  of  vary- 
ing degrees  of  development,  resulting  in  what  we  call  abortion 
or  miscarriage.  We  give  to  this  latter  phenomenon  when  re- 
peated the  title  of  habitual  miscarriage.  In  other  words,  there 
is  during  pregnancy  a  constant  struggle  on  the  part  of  the  en- 
docrines concerned  in  menstruation,  to  produce  it,  and  a  strug- 
gle on  the  part  of  the  ovum  and  the  secretion  produced  by  its 
outer  covering,  to  inhibit  menstruation.  This  struggle  between 
the  two  opposing  forces  comes  to  a  crisis  on  the  two  hundred 
and  eightieth  day  in  what  we  call  a  labor.  But  here  again  not 
infrequently,  inhibition  allows  the  patient  to  go  some  days  to 
weeks  over  her  expected  date;  other  patients  are  delivered  a 
few  days  or  weeks  before  the  two  hundred  and  eightieth  day. 
Of  course,  in  many  cases  this  is  due  to  the  fact  that  ova  may 
be  fecundated  immediately  after  a  menstruation,  while  other 
ova  are  fecundated  shortly  before  the  first  skipped  menstrua- 


192  THE    ENDOCRINES 

tion.  The  treatment  of  these  latter  conditions — the  type  of  in- 
dividual who  goes  a  week  or  ten  days  over  her  period,  occasion- 
ally, when  she  otherwise  menstruates  normally,  and  including 
all  the  various  types  with  a  tendency  to  menstruate  during  preg- 
nancy— consists  of  trophic  stimulation  first  and  then  of  inhibi- 
tion of  the  menstrual  stimulus.  We  have  used  for  this  pur- 
pose rest  in  bed,  the  administration  of  opiates  and  sedatives; 
but  instead  of  waiting  and  depending  upon  treating  cases  of 
habitual  abortion  only  when  the  symptoms  of  expulsion  of  the 
ovum  develop,  or  inste?d  of  relying,  as  we  have  been  wont 
to  do,  on  the  theory  that  these  cases  must  on  examination  evi- 
dence a  positive  Wassermann  (which  is  far  from  the  truth), 
we  administer  endocrines  which  act  trophically  on  the  uterus 
or  which  inhibit  the  menstrual  stimulus,  and  our  results  im- 
prove in  certainty. 

It  is,  of  course,  the  most  desirable  part  of  our  therapy 
to  administer  the  endocrines,  either  for  the  purposes  of  trophic 
stimulation  or  for  the  purposes  of  inhibition,  on  the  basis  of  a 
study  of  the  individual's  endocrine  make-up,  seeking  to  find  in 
each  and  every  case,  if  possible,  the  special  factor  or  factors 
which  are  at  the  bottom  of  either  condition.  But  even  if  this 
is  difficult  or  impossible,  we  do  know  that  the  ovary  and  its 
secretions,  both  of  the  interstitial  and  of  the  glandular  ap- 
paratus, have  a  decided  trophic  relation  to  the  well-being  of 
the  genitalia.  We  know  that  the  thyroid  gland  bears  a  close 
nutritive  value  to  the  genital  functions,  and  that  the  adrenal 
cortex  likewise  bears  an  Important  part  of  this  trophic  burden. 
As  to  the  hypophysis,  we  know  from  the  study  of  the  physi- 
ology of  the  gland  that  its  relation  to  the  genital  tract  is  close 
and  that  affections  of  the  hypophysis  may  influence  menstrua- 
tion and  the  development  of  the  uterus  for  either  better  or 
worse. 

The  anterior  lobe,  concerned  as  it  is  with  the  general  pro- 
cess of  body  growth,  includes  within  the  field  of  its  activities 
the  development  and  function  of  the  genitalia.  The  posterior 
lobe,  as  can  be  understood  from  its  action  in  labor,  is  concerned 
with  the  rhythmic  uterine  contractions  of  the  same ;  hence  my 


THE  "higher  up"  THEORY  OF  STERILITY  IN  WOMEN      193 

conclusion  that  overactivity  of  the  posterior  lobe  at  menstrua- 
tion is  responsible  in  most  cases  for  uterine  dysmenorrhea — 
and  therapy  proves  this  to  be  true. 

The  thymus  gland  has  the  effect  in  some  cases  of  inhibit- 
ing ovarian  activity.  Based  on  physiological  study,  extract  of 
the  placenta  should  have  a  quieting  and  inhibiting  effect  on 
overactivity  of  the  posterior  pituitary.  Proceeding  from  this 
basis,  I  have  used  it  in  a  very  large  series  of  cases  and  have 
found  it  to  be  of  the  greatest  value  in  those  cases  of  dysmenor- 
rhea and  repeated  miscarriage  and  in  a  large  number  of  pelvic 
conditions  and  general  states  due  to  posterior  pituitary  hyper- 
activity. Inasmuch  as  the  use  of  placental  extract  in  threatened 
or  repeated  miscarriages  has  always  been  associated  with  the 
use  of  other  endocrines  and  occasionally  with  the  use  of  seda- 
tives, the  reliance  that  may  be  placed  on  this  extract  alone  is 
not  yet  settled  in  my  mind. 

Since  working  on  this  theory  and  following  this  practice, 
I  find  results  which,  in  comparison  with  the  results  obtained 
by  other  methods  are  not  only  encouraging  but  decidedly  effec- 
tive, I  have  not  the  faintest  interest  in  proving  that  dilatation 
and  curettage  are  never  followed  in  previously  sterile  patients 
by  subsequent  pregnancy,  for  the  record  and  experience  of  able 
men  in  gynecology  proves  that  it  is  true.  I  simply  feel  that 
curettage  and  dilatation  and  cervical  plastics  have  not  attacked 
the  basic  factors  which,  in  the  majority  of  cases,  in  my  belief 
and  in  my  experience,  are  of  greater  importance.  What  pos- 
sible error  is  a  physician  committing  if  he  treats  a  case  of  cur- 
able sterility  by  endocrines  before  he  attempts  any  surgical 
procedure?  Then,  if  this  treatment  is  not  successful,  he  is  the 
more  justified  in  assuming  that  some  surgical  procedure  is 
necessary.  The  fact  that  he  may  decide  on  a  cervical  opera- 
tion, while  I  would  be  more  inclined  to  advise  the  removal  of 
cysts  from  the  ovaries,  would  then  furnish  a  basis  on  which 
we  could  eventually  accurately  measure  the  role  which  the  cer- 
vix plays  as  an  obstacle  to  impregnation.  And  when  it  comes 
to  the  question  of  curettage,  with  the  subsequent  restoration 
of  a  new  endometrium,  I  hold  that  unless  the  endometrium  is 


194  THE    ENDOCRINES 

overgrown  or  polypoid,  endocrine  therapy  restores  it  to  a  type 
and  character  favoring  nidation  just  as  well  if  not  better  and 
with  less  danger.  We  must  understand  the  difference  between 
fecundation  and  that  continuance  of  nesting  and  growth  of 
the  ovum  which  we  call  pregnancy ;  and  I  am  firmly  convinced 
that,  whatever  endocrine  therapy  does  to  the  ovary  or  tubes, 
in  a  large  proportion,  if  not  the  largest,  it  acts  trophically  in 
aiding  the  ovum  to  nest  or  in  retaining  it  after  it  sinks  into  the 
endometrium.  In  other  words,  union  of  the  ovum  and  sperma- 
tozoon occur  in  an  untold  number  of  cases,  but  nidation  or 
permanent  nidation  fails. 

If  this  be  true,  it  is  sad  to  think  of  the  innumerable  un- 
born, still  remaining  in  the  Blue-Bird  Land  of  Maeterlinck, 
whose  potential  mothers  might  have  permitted  them  ingress 
into  this  mundane  sphere. 

The  maternal  instinct  can  be  one  of  the  most  powerful 
of  all  instincts  but  is  of  varying  degree.  The  same  holds  true 
of  the  sex  instinct.  But  while  both  are  associated  with  en- 
docrine stimuli,  both  trophic  and  otherwise,  there  is  a  vast  dif- 
ference here  in  the  intensity  of  the  somatic  effects  and  in  the 
intensity  of  those  psychic  phenomena  connected  with  either  of 
these  instincts  and  their  associated  emotions.  An  individual 
may  have  a  strong  maternal  instinct  and  little  sex  urge  or 
receptivity ;  and  many  women  reconcile  themselves  to  the  sexual 
side  of  married  life  because  thereby  comes  the  subsquent  re- 
ward of  maternity.  Others  have  the  physical  and  psychic  sex 
phenomena  of  normal  or  exaggerated  character  with  little  of 
the  maternal  instinct.  Children  give  pleasure,  joy,  or  sorrow 
according  to  the  accidents  and  fates  of  life  which  are  theirs; 
and  these  depend  much  on  the  moulding  and  development  of 
their  instincts,  emotions,  disposition,  and  character.  Parents 
take  the  chances  associated  with  heredity,  environment,  train- 
ing, education,  etc.,  and  the  developing  child  is  the  product. 
Sterility,  according  to  the  instincts,  emotions,  disposition,  and 
character  of  the  patient  may  be  accepted  with  indifference,  with 
regret,  or  with  a  continued  yearning  or  longing;  and  because 


THE  "higher  up"  THEORY  OF  STERILITY  IN  WOMEN      195 

of  it  psychic  effect  may  spoil  or  destroy  the  desiring-to-be- 
mother's  life. 

The  correction  of  sterility  does  not,  as  is  the  province  of 
medicine,  simply  benefit  a  mental  state,  correct  an  ill,  or  save 
life;  it  helps  to  create  life. 

I  have  never  told  a  patient  that  the  fault  is  her  husband's, 
however  often  this  may  be  the  case.  Sterility  is  so  frequently 
productive  of  depression  and  psychic  disturbances,  the  causes 
of  domestic  infelicity  are  numerous  enough,  why  add  this  new 
brand  to  a  smouldering  or  even  brighter  flame?  I  tell  the  pa- 
tient to  take  the  medication  for  several  weeks  only,  that  it  may 
produce  a  favorable  effect  only  after  months  or  years ;  or  that 
causes  which  we  cannot  discern  and  correct  may  right  them- 
selves even  after  a  long  interval  of  time.  The  disadvantage  of 
this  advice  is  that  it  makes  the  patient  think  the  method  is 
useless  (which  is  a  burden  physicians  have  to  bear  continually 
in  their  practice) .  Another  disadvantage  is  that  it  often  throws 
the  patient  into  hands  favorable  to  dilatation,  to  curettage, 
discission,  or  cervical  plastic,  regardless  of  or  in  ignorance  of 
the  absence  of  spermatozoa.  Perhaps  this  is  not  always  so 
unfortunate  a  result,  for  the  patient  then  feels  that  she  has 
exhausted  every  known  means  for  the  treatment  of  her  sterility. 
Time,  plus  resignation  and  philosophy,  may  then  remove  the 
too  absorbing  mental  concentration. 

In  "The  Medical  Clinics  of  North  America,"  ii,  4,  I  tabu- 
lated a  series  of  fifty  cases  of  sterility  showing  the  number  due 
to  absent  or  inactive  spermatozoa,  the  cases  which  did  not  be- 
come pregnant,  though  spermatozoa  were  normal,  and  the  cases 
which  became  pregnant — five  after  operation  on  the  tubes  or 
ovaries  and  twelve  after  endocrine  therapy. 

The  purpose  of  this  tabulation  was  an  attempt  to  show 
th€  relative  importance  of  tuboovarian  conditions,  absent  or 
faulty  spermatozoa,  and  marked  alterations  in  menstruation  in 
their  relation  to  sterility,  and  by  reporting  the  proportion  of 
cases  cured  by  endocrines,  to  arrive  at  various  conclusions  con- 
cerning the  entire  question  of  sterility. 


CHAPTER    X 

PREGNANCY,   LABOR,   AND   THE   PLACENTAL 

GLAND 

In  individuals  growing  normally  and  developing  prop- 
erly the  ovaries  come  to  maturity  and  develop  properly  if  they 
are  sustained  and  nourished  by  a  proper  secretory  relation  on 
the  part  of  the  thyroid,  the  adrenals,  and  the  hypophysis.  Be- 
fore puberty  an  inhibiting  action  on  the  sex  organs  by  the 
pineal  gland  and  the  thymus  gland  is  removed  and,  with  all 
these  conditions  fulfilled,  normally  developed  internal  and  ex- 
ternal genitalia  are  present  and  menstruation  begins  at  the 
proper  time  and  recurs  regularly  without  any  marked  annoy- 
ing phenomena,  provided  that  the  infectious  diseases  of  child- 
hood have  not  affected  the  ovaries,  or  their  supporting  glands. 

A  disturbance  in  the  nutritional  functions  of  the  thyroid, 
the  hypophysis,  and  adrenals  of  especial  magnitude  interferes 
with  the  proper  development  of  the  genitalia  and  the  ovaries. 
Unusually  prolonged  or  permanent  inhibition  by  the  pineal 
gland  or  the  thymus  results  in  failure  of  proper  action  on  the 
part  of  the  ovaries.  On  the  other  hand,  in  a  certain  number 
of  cases,  a.  too  early  removal  of  the  inhibitory  action  of  the 
thymus  and  pineal  gland  or  a  marked  stimulation  by  the  other 
three  glands  results  in  an  early  maturation  of  the  ovaries  and 
very  early  activity.  It  is  an  old  saying  that  normal  menstrua- 
tion implies  ovaries  capable  of  producing  ripe  ova.  I  think  in 
the  light  of  modern  medicine  that  this  opinion  must  be  modi- 
fied considerably.  A  woman  may  menstruate  and  menstruate 
early  and  yet  the  ovaries  and  the  Fallopian  tubes  may  not  be 
functioning  normally.  The  ciliated  epithelium  of  the  Fallopian 
tubes  is  under  the  trophic  influence  of  the  ovaries  and  probably 
the  thyroid  and  hypophysis.  If  the  cilia  do  not  function,  no 
tube  can  send  an  ovum  into  the  uterus.  I  believe  that  in  many 
.  instances  there  are  ovaries  which  for  various  reasons  do  not 
expel  ova ;  that  is,  they  do  not  liberate  the  ova  from  the  ovary. 
A  Graafian  follicle  approaches  the  surface  but  something  is 

196 


PREGNANCY,    LABOR,    AND   THE   PLACENTAL   GLAND       197 

lacking  which  normally  breaks  the  follicle  and  expels  the  ovum. 
Normally  there  must  be  something  in  the  ovum,  in  the  follicle, 
and  in  the  cells  lining  the  follicle  whose  ferment  action  dis- 
solves the  outer  covering  of  the  ovary  and  thus  liberates  the 
liquor  folliculi  with  the  enclosed  egg.  Beside  cases  where 
this  ferment  action  is  not  present  there  may  be  cases  where 
the  tunica  albuginea  is  unusually  thick  and  unusually  resistant. 
If  we  believe  in  the  relation  of  the  ovary  to  the  other  internal 
secretory  glands,  if  we  believe  in  their  trophic  care  of  the 
ovaries  and  genitalia,  if  we  believe  in  the  inhibiting  action  of 
some  of  these  secretions  on  the  ovary,  we  must  conclude  log- 
ically that  there  are  many  cases  where  the  ovaries  do  not  lib- 
erate the  ovum.  In  other  words,  ovulation  in  the  strictest 
sense  does  not  occur.  Wq  then  have  in  these  ovaries  retained 
follicles,  the  so-called  atresic  follicles.  Numerous  cases  show 
these  atresic  follicles  in  excessive  number.  Trophic  support 
by  the  pituitary  posterior  lobe  is  lacking. 

One  function  of  the  true  corpus  luteum  cells  is  to  inhibit 
the  maturation  and  breaking  of  follicles  during  the  period  of 
pregnancy.  With  atresic  follicles,  with  unbroken  follicles,  with 
corpus  luteum  cysts,  and  with  unabsorbed  corpus  luteum  cen- 
ters of  smaller  or  larger  size,,  there  is  exerted  on  the  follicles 
an  inhibitory  action  and  this  may  likewise  be  one  of  the  very 
frequent  causes  for  the  failure  of  ovulation  to  take  place  in 
the  nonpregnant. 

I  believe  the  hypophysis  has  much  to  do  with  this  in- 
hibitory action  on  the  ovary ;  inhibitory  not  in  the  active  sense, 
but  most  probably  inhibitory  in  that  the  proper  stimulation  is 
not  given.  Dystrophia  adiposogenitalis  is  the  extreme  type. 
So  I  believe  that  it  may  be  concluded  that  a  large  proportion  of 
cases  of  sterility  in  which  spermatozoa  are  present  in  the  male, 
in  which  no  inflammatory  changes  are  present  in  the  cervix, 
uterus,  or  tubes,  and  in  which  obstruction  of  a  positive  type 
is  not  present,  are  to  be  considered  as  due  to  failure  of  ovula- 
tion. I  have  proved  this  to  my  satisfaction  by  several  suc- 
cessful results  after  "wedge  resection"  of  both  ovaries.  I 
mention  these  facts  in  this  chapter  in  order  to  show  how  in- 


198  THE    ENDOCRINES 

timately  connected  are  the  other  glands  of  the  body  to  those 
glands  which  are  specially  related  to  the  nutrition  of  the  uterus 
and  the  decidua  and  to  the  function  of  menstruation  and  ovu- 
lation. 

The  development  of  the  secondary  sex  characteristics  de- 
pends upon  the  ovaries  through  the  co-operation  of  the  other 
glands  and  by  action  of  the  other  glands  themselves.  The  de- 
velopment of  the  mammary  glands  is  especially  under  the 
action  of  the  ovary.  No  matter  how  well  the  other  glands 
function,  if  the  ovaries  are  removed  in  the  early  years  a  failure 
of  development  of  the  internal  genitalia,  the  mammae,  and  the 
secondary  sex  characteristics  occurs;  and  if  this  occurs  after 
puberty  then  atrophy  of  these  various  organs  takes  place,  most 
particularly,  however,  in  the  sphere  of  the  genital  tract.  Our 
attention  is  thus  fixed  on  the  value  of  the  secretion  developed 
by  the  ovary,  by  the  interstitial  structure,  by  the  follicles  them- 
selves, and  by  that  substance  known  as  the  true  corpus  luteum 
which  develops  excessively  before  menstruation  and  continues 
only,  under  normal  conditions,  when  pregnancy  exists. 

Now  the  ovaries  are  responsible  for  menstruation  through 
the  action  of  the  vegetative  nervous  system  and  more  so 
through  direct  action  of  the  secretions  on  the  tubes,  uterus, 
and  its  lining  through  the  medium  of  their  circulation.  That 
the  corpus  luteum  plays  an  important  trophic  part  is  not  to  be 
doubted,  but  it  is  also  a  secretion  produced  by  the  ovary. 

We  know  in  a  general  way  the  action  of  these  various 
secretory  glands  and  we  know  more  and  more  each  day  of 
their  interactivity,  and  how  a  failure  in  the  way  of  overaction 
or  underaction  on  the  part  of  one  influences  the  whole  cycle. 
Now,  into  this  realm  of  interglandular  activity  there  enters  a 
new  phase  in  pregnancy.  When  an  impregnated  ovum  comes 
into  the  uterus  and  imbeds  itself  in  the  overgrown  decidua 
by  enzyme  action  inherent  in  itself,  menstruation  fails  to  take 
place.  Menstruation  is  preceded  by  a  tremendous  hyperemia 
of  the  lining  of  the  uterus,  increase  in  size  and  thickness  of  the 
endometrium,  and  a  dilatation  of  the  capillaries.  The  secretion 
of  the  ovarian  tissue  tends  to  diminish  the  coagulability  of  the 


PREGNANCY,   LABOR,    AND   THE   PLACENTAL  GLAND       199 

blood,  and  the  glands  of  the  decidua  secrete  a  substance  which 
probably  has  the  same  action.  Through  the  action  of  ovarian 
secretion  aided  by  pituitary  secretion  capillaries  break  through 
rhexis  and  there  is  a  diapedesis  of  red  blood  cells  and  contrac- 
tions of  the  uterus.  Only  blood  is  thrown  off ;  the  decidua  re- 
mains behind  after  menstruation  like  a  wet  sponge  from  which 
the  water  has  been  expressed.  These  processes  are  inhibited 
when  a  fecundated  ovum  is  in  the  decidua.  We  know  that  cells 
given  off  from  the  outer  layer  of  an  impregnated  ovum  are 
thrown  into  the  circulation  as  soon  as  it  is  imbedded.  Slight  as 
this  amount  must  be  in  the  early  days  of  pregnancy  it  is  suffi- 
cient through  the  medium  of  the  circulation,  thence  reaching 
the  ovary,  stimulating  the  corpus  luteum,  and  acting  on  the 
uterine  lining  and  continuing  to  circulate  in  the  blood,  to  inhibit 
menstruation,  though  hyperemia  and  congestion  present  in  the 
uterine  mucosa  continue,  but  rhexis  and  diapedesis  are  inhib- 
ited. The  trophoblast  cells  of  an  impregnated  ovum  are 
primarily  responsible  for  this. 

The  next  change  produced  by  the  trophoblast  cells  is  in 
the  reaction  produced  in  the  corpus  luteum.  This  body  does 
not  regress  as  it  does  when  pregnancy  does  not  take  place;  it 
simply  continues  its  growth  for  a  period  of  many  months. 
This  continued  growth  and  function  of  a  corpus  luteum  is 
undoubtedly  a  reaction  produced  by  the  trophoblast  cells.  This 
corpus  luteum  is  important.  It  continues  its  nutritional  effect 
upon  the  uterus  and  particularly  upon  the  decidua,  inhibits 
menstruation,  aids  the  continued  attachment  of  the  ovum  and 
probably  exerts  a  protective  influence  in  preventing  too  great 
an  encroachment  into  the  decidua  and  later  into  the  uterus  of 
the  trophoblast  and  syncytial  cells. 

The  nutritional  action  of  the  true  corpus  luteum  is  of 
far  greater  importance  in  the  first  months  of  pregnancy  than 
it  is  later  on  for  it  aids  the  trophoblast  in  inhibiting  the  pos- 
terior pituitary.  Later  on  the  ovum  has  developed  to  a  consid- 
erable size,  a  placenta  has  formed,  the  entire  ovum  fills  out 
the  cavity  of  the  uterus,  and  the  periphery  of  the  ovum  is 
agglutinated  to  the  entire  interior  of  the  uterine  cavity.     The 


200  THE    ENDOCRINES 

uterus  in  these  early  months  grows  rapidly,  more  rapidly  than 
would  be  expected  by  the  simple  stretching  effect  of  the  ovum. 
The  ovum  hangs  by  a  pedicle  in  the  early  weeks  and  does  not 
by  any  means  fill  out  the  cavity  of  the  uterus.  Yet  the  uterus 
grows.  It  does  so  even  in  cases  of  ectopic  gestation.  Here 
we  see  the  continued  stimulation  by  the  anterior  pituitary, 
adrenal  cortex,  thyroid,  etc.,  secretions  trophic  in  their  nature, 
and  the  uterus  and  the  decidua  well  supplied  with  blood.  The 
blood  contains  the  secretion  of  the  ovary  which  would  have 
been  expelled  and  lost  had  menstruation  taken  place.  Thus 
the  placental  secretion  plays  an  important  part  in  stimulating 
the  growth  of  the  uterus. 

The  next  process  is  the  effect  of  the  trophoblast  secretion 
upon  the  hypophysis  gland.  The  anterior  lobe  hyperfunctions 
and  the  change  in  its  cells  is  a  permanent  one.  We  know  what 
the  anterior  lobe  does  in  the  process  of  growth,  bone  enlarge- 
ment, and  sexual  development ;  and  we  must  consider  this  and 
other  gland  activity  as  a  protective  or  trophic  secretion 
designed  to  help  the  patient  herself,  probably  designed  to  help 
the  ovum,  the  uterus,  and  the  decidua  in  these  early  months 
with  probably  a  greater  effect  on  the  patient  and  embryo  in  the 
later  months. 

The  painless  contractions  of  Braxton  Hicks  are  probably 
due  to  corpus  luteum,  but  much  more  to  the  posterior  lobe  of 
the  hypophysis,  and  are  a  continuation  of  the  automassage 
ever  present  in  the  normal  uterus.  The  increased  activity  and 
size  of  the  thyroid,  too,  and  the  changes  going  on  in  the 
adrenals  and  other  glands,  may  be  viewed  in  the  light  of  an 
increased  trophic  effect  on  the  genitalia,  probably  giving  off  to 
the  patient  certain  protective  substances.  The  patient  in  preg- 
nancy needs  protective  substances  because  the  trophoblast  and 
later  placental  secretion  are  entirely  new  elements  and  the  body 
must  react  to  it  through  the  medium  of  the  other  secretory 
glands  and  through  the  production  in  the  blood  of  other  pro- 
tective substances  as  in  fevers  and  other  diseases. 

The  earliest  evidences  of  the  irritating  effects  of  the 
trophoblast  and  later  placental  secretion  are  to  be  found  in  the 


PREGNANCY,   LABOR,    AND   THE   PLACENTAL  GLAND      201 

nausea  and  vomiting  of  pregnancy.  This  new  substance  is  an 
irritant.  It  irritates  the  cerebral  centers  and  the  posterior  pitu- 
tary,  for  this  reason  having  an  irritating  action  on  the  gastric 
mucosa,  the  pylorus,  and  the  liver.  \\'hether  the  premenstrual 
hyperemia  and  congestion  which  take  place  in  every  part  of 
the  body  and  which  are  associated  with  dilatation  of  the 
cerebral  vessels,  heightened  by  the  continuous  action  of  the 
corpus  luteum,  play  a  part  in  this  process  can  only  be  sur- 
mised. At  any  rate  we  are  justified  in  considering  that  the 
secretion  produced  by  the  outer  cells  of  the  ovum  and  later 
by  the  placenta  is  the  irritating  substance  which  is  primarily 
responsible  for  the  nausea  and  vomiting.  In  whatever  degree 
the  body  reacts  to  this  and  produces  the  protective  endocrine 
substances,  in  that  degree  is  the  nausea  and  vomiting  either 
stopped  or  continued.  If  we  consider  that  the  corpus  luteum  of 
pregnancy  is  continued  as  a  reaction  to  this  placental  secretion. 
we  ought  to  look  upon  the  corpus  luteum  as  an  aid  in  stopping 
the  nausea.  Alany  observations  in  this  direction  have  been 
made  and  it  has  been  claimed  that  the  injections  of  corpus 
luteum  extract  into  these  patients  stops  the  nausea  and  vomit- 
ing. Theoretically  the  idea  is  splendid  and  rational ;  in  practice 
opinions  vary.  J\Iany  are  enthusiastic  over  it.  I  have  not  yet 
had  striking  success  with  this  procedure,  but  corpus  luteum  by 
mouth  and  injections  of  corpus  luteum  are  of  value  if  they 
succeed  in  inhibiting  the  posterior  pituitary.  At  any  rate,  in  the 
vast  majority  of  cases  these  annoyances  in  the  way  of  nausea 
leave  permanently  at  the  time  that  life  is  felt.  In  many  cases 
this  condition  may  be  excessive,  taxing  our  resources  to  the 
utmost,  and  in  some  cases  pregnancy  must  be  interrupted  to 
avoid  penTianent  or  fatal  harm  to  the  patient.  In  these  cases 
the  protective  substances  that  are  produced  by  the  ovary,  the 
liver,  the  hypophysis,  the  thyroid,  or  the  system  in  general,  are 
not  produced  in  sufficient  amounts  or  proper  character,  and  a 
condition  of  pernicious  nausea  and  vomiting  or  early  toxemia  is 
present.  The  transient  albuminuria  present  in  some  cases  in 
the  early  months  is  probably  due  to  the  irritating  effect  of  this 
placental  secretion  or  to  hypothyroidism.     Overstimulation  of 


202  THE    ENDOCRINES 

the  posterior  pituitary  is,  with  thyroid  minus,  the  basic  endo- 
crine factor  in  the  toxemia  of  pregnancy. 

Many  patients  in  pregnancy  show  quite  a  growth  of  the 
body,  a  growth  sufficiently  noticeable  to  attract  attention.  The 
tonic  effect  is  remarkable.  Many  show  at  various  periods  an 
acromegalic  hyperplasia.  A  transitory  thickening  of  the  skin 
of  the  face  and  a  suggestion  of  edema  are  also  decidedly  sug- 
gestive of  a  hypophysis  change  allied  to  acromegaly.  Here  we 
are  confronted  with  the  stimulative  changes  in  the  anterior  lobe 
of  the  hypophysis,  a  reaction  undoubtedly  produced  by  the 
action  of  the  placental  secretion. 

We  next  come  to  the  transient  glycosuria  present  in  many 
cases  during  the  various  months  of  pregnancy.  It  is  found 
intermittently  in  many  cases  where  routine  examinations  of 
the  urine  are  made.  This  draws  attention  to  the  pancreas,  to 
the  liver,  and  to  the  hypophysis,  and  possibly  to  the  mammary 
gland  (lactosuria).  A  transient  or  even  a  marked  involve- 
ment of  the  pancreas  function  may  occur  and  there  may  be  a 
disturbed  relation  between  the  thyroid  and  the  pancreas.  There 
may  be  the  liver  type  of  glycosuria.  Possibly  the  mammary 
gland  may  have  an  effect.  For  the  most  part  we  must  look 
to  the  hypophysis  as  responsible  for  this  condition.  So  far, 
it  is  known  that  a  more  or  less  marked  glycosuria  may  appear 
with  transient  hj^perfunction  of  the  h3^pophysis  particularly  of 
the  posterior  lobe.  This  factor  plus  the  changes  occurring  in 
the  anterior  lobe  speaks  for  the  excessive  or  increased  action 
of  the  hypophysis,  at  least  part  of  it,  a  reaction  probably  due 
directly  or  indirectly  to  the  placental  secretion.  That  true 
diabetes  may  be  unfavorably  affected  by  pregnancy,  and  that 
it  is  a  most  serious  condition,  is  known  to  everyone. 

The  mammary  gland  is  also  stimulated  in  pregnancy.  It 
often  reacts  to  the  premenstrual  stimulus  of  the  corpus  lu- 
teum.  It  increases  in  size  after  labor  and  its  secretory  func- 
tions are  finally  established  after  a  preliminary  hyperemia. 
Injections  of  various  substances  increase  the  function  of  the 
mammary  gland.  Fetal  extract  used  experimentally  stimu- 
lates   this    gland.       So    does    corpus    luteum.      Placental  ex- 


PREGNANCY,   LABOR,    AND   THE   PLACENTAL  GLAND      203 

tract  and  pituitrin  will  accomplish  the  same  result.  The  most 
that  may  be  said  is  that  the  mammary  gland  is  acted  on  during 
pregancy  probably  by  the  ovary,  possibly  by  the  fetus,  but 
most  probably  by  the  placental  secretion  and  the  posterior  pitu- 
itary. After  labor,  when  these  stimulating  factors,  though 
apparently  inhibited  before,  are  no  longer  inhibited  by  the 
placenta  and  a  degenerating  or  secretory  process  occurs,  milk  is 
secreted  instead  of  colostrum.  Whether  the  hypophysis  has 
anything  to  do  with  this  before  or  after  labor  is  not  known,  but 
some  consider  the  hypophysis  secretion  a  remarkable  galacto- 
gogue.  It  is  safe  to  say  that  no  one  known  substance  will  posi- 
tively produce  a  well  functioning  breast.  Thyroid  extract  has 
been  used,  pituitary  extract  has  been  used,  placental  extract  has 
been  used,  corpus  luteum  has  been  used.  I  have  tried  each  one 
of  them  and  am  as  yet  unable  to  say  that  any  one  or  a  combina- 
tion of  them  will,  with  any  degree  of  certainty,  produce  milk  in 
every  breast.  My  experience  has  been  that  breasts  either  secrete 
readily  or  not,  and  no  regime  of  food,  diet,  or  tonic  treatment 
will  do  more  than  add  a  stimulus.  My  later  experience  has 
been  that  a  very  small  percentage  of  women  are  able  without 
endocrine  aid  to  nurse  their  children  sufficiently  for  several 
months. 

It  must  be  kept  in  mind  that  the  ovum  and  the  placenta 
are  a  parasite.  The  nourishment  of  the  fetus  taxes  the  re- 
sources of  the  mother,  but  this  burden  in  the  majority  of 
cases  is  not  an  excessive  one,  if  the  heart  and  kidneys  are  nor- 
mal. I  formerly  believed  that  cardiac  diseases  could  with 
great  care  bear  the  burden  of  a  pregnancy.  \\'ith  increasing 
experience  I  am  very  loath  to  allow  a  patient  with  marked 
cardiac  lesion  to  be  endangered  for  nine  months  by  pregnancy 
and  labor.  It  is  not  the  tax  on  the  general  system  alone.  There 
is  something  in  the  ovum  and  in  the  placenta  which  through  its 
action  on  the  other  endocrines  exerts  a  markedly  injurious 
action  on  the  heart  muscles,  on  valvular  lesions,  and  on  the 
cardiac  centers  which  encourage  and  control  the  rhythm  and 
the  force  of  the  beat.  In  these  changes  and  alterations  lie 
the  danger  of  pregnancy  with  marked  cardiac  lesion. 


204  THE    ENDOCRINES 

If  the  Barnes  or  Champetier  de  Ribes  bag  be  introduced 
into  the  cervix,  this  dilatation  of  the  cervix  causes  uterine  con- 
tractions at  first  painless.  These  are  not  felt  by  the  patient  as 
pains.  There  is  a  feeling  of  discomfort  and  a  sense  of  pressure 
in  the  back.  After  hours,  sometimes  after  many  hours,  labor 
pains  come  on.  Not  infrequently  a  second  or  a  third  bag  must 
be  introduced  before  the  uterus  goes  into  rhythmical  contrac- 
tions. If,  however,  after  the  introduction  of  a  Barnes  or  a 
Champetier  de  Ribes  bag,  pituitrin  in  small  doses  is  given 
regularly,  rhythmical  labor  pains  come  on  and  many  hours  of 
waiting  are  saved.  It  is  almost  never  necessary  to  introduce 
a  second  bag. 

If  the  membranes  rupture  before  labor  sets  in,  it  takes 
from  six  or  eight  hours  to  three  days  before  labor  pains  come 
on  spontaneously.  If  after  the  membranes  have  ruptured  even 
days  or  weeks  before  labor  is  expected,  pituitrin  is  adminis- 
teerd  in  small  doses  at  regular  intervals,  it  will  bring  on 
rhythmical  contractions  and  the  patient  goes  into  labor  within 
a  very  short  time.  Removal  of  the  liquor  amnii  causes  some 
contraction  of  the  uterus  and  possibly  some  stimulation  or 
secretion  of  the  decidua,  and  dilatation  of  the  cervix  by  a 
Barnes  bag  causes  contractions  of  the  uterus  with  possibly 
some  effect  upon  the  decidua.  The  uterus  is  sensitized,  the 
pituitary  gland  is  stimulated,  and  for  that  reason  the  adminis- 
tration of  pituitrin  is  effective. 

It  has  long  been  known  that  the  administration  of  castor 
oil  at  or  about  full  term  has  a  certain  effect  in  bringing  on 
labor  pains.  We  all  know  the  value  of  quinine  in  increasing 
the  force  of  labor  pains.  It  may  be  taken  for  granted  that 
each  of  these  substances  sensitizes  the  uterus  and  makes  it  more 
susceptible  to  the  action  of  the  pituitary  posterior  lobe. 

Acting  on  this  theory,  I  tried  the  following  procedure  to 
a: void  the  use  of  the  Barnes  bag:  At  7  a.  m.  an  ounce  and  a 
half  of  castor  oil  was  administered,  and  three  hours  later  at 
half  hour  intervals  ten  grains  of  quinine.  One  or  two  hours 
after  the  last  dose  of  quinine,  two  to  five  minims  of  pituitrin 
were  given  every  half  hour  for  several  hours.  This  method  was 


PREGNANCY,    LABOR,    AND    THE   PLACENTAL   GLAND       205 

effectual  in  many  instances  in  bringing  the  regular  rhythmical 
labor  pains  and  sending  the  patient  into  a  normal  labor,  I 
found  this  procedure  perfectly  reliable  in  over  eighty  per  cent, 
of  multigravidce  when  tried  within  a  week  or  ten  days  of  the 
expected  labor  period.  In  fifty  per  cent,  of  primigravidse  it 
is  effectual  at  or  about  the  time  at  which  labor  is  expected. 
If  this  method  is  tried  from  two  to  three  weeks  before  the 
expected  time,  the  effect  is  by  no  means  so  good  and  in  many 
cases  has  no  result  at  all. 

The  ovary  nourishes  the  uterus,  making  it  grow,  but 
causes  regular  bleeding.  The  placenta  nourishes  the  uterus, 
making  it  grow,  but  stops  bleeding.  If  the  corpus  luteum  acts 
on  the  hypophysis  posterior  lobe  and,  though  it  ought  to  in- 
hibit it,  makes  it  overact  instead  of  underact  at  menstruation, 
we  often  observe  menstrual  pain  simulating  that  of  labor  and 
called  dysmenorrhea.  Corpus  luteum  and  the  posterior  pitui- 
tary lobe  act  as  antagonists  in  menstruation.  The  placental 
secretion  normally  inhibits  the  posterior  lobe  as  well  as  does 
the  corpus  luteum  and  no  menstruation  takes  place,  only 
painless  contractions. 

With  an  ovum  full  of  atresic  follicles  and  corpus  luteum 
rests  ovulation  is  often  inhibited,  but  the  stimulation  to  the 
posterior  lobe  is  not  present,  coagulation  takes  place  slowly  or 
quickly  and  diminished  or  excessive  menstruation  occurs,  ac- 
cording to  the  reaction  of  the  postpituitary,  but  no  ovulation, 

It  would  be  wise  to  try  the  effect  of  placental  secretion 
on  dysmenorrhea,  because  of  this  theoretical  inhibition  by  its 
action  on  posterior  hypophysis  either  directly  or  through  the 
corpus  luteum.  If  placental  extract  stimulates  the  anterior 
lobe  of  the  hypophysis  it  might  be  advisable  to  use  this  extract 
in  cases  where  it  is  desired  to  stimulate  growth  in  children, 
with  the  administration  of  hypophysis  extract  also. 

If  the  corpus  luteum  in  any  case  rouses  the  posterior  lobe 
of  the  hypophysis,  causing  menstrual  pain,  then  corpus  luteum 
is  not  indicated  at  all  in  dysmenorrheas. 

But  if  placental  extract  inhibits  the  posterior  lobe  of  the 
hypophysis  and  holds  its  contractile  powers  in  abeyance  for 


206  THE    ENDOCRINES 

months,  then  it  might  be  wise  to  give  placental  extract  for 
dysmenorrhea.  If  ovarian  extract  and  ovarian  residue  stimu- 
late the  uterus  and  its  lining,  causing  diapedesis  and  rhexis, 
and  if  placental  extract  results  in  growth  of  the  uterus  but 
overcomes  diapedesis  and  rhexis,  then  we  should  give  placental 
extract  in  cases  where  excessive  menstruation  is  due  to  hyper- 
ovarianism.  We  may  thus  dissociate  the  function  of  the  ovary 
and  pituitary  as  nutritional  factors  of  the  uterus,  from  their 
function  in  causing  menstrual  bleeding.  And  we  must  think  of 
the  placenta  as  an  organ  which  directly  or  through  its  effect 
on  corpus  luteum  nourishes  the  uterus  and  its  lining  but  which 
overcomes  its  tendency  to  bleed. 

Therefore,  even  if  ovarin  is  contraindicated  in  menor- 
rhagia,  this  may  be  overcome  by  placental  extract.  If  the 
decidua  stimulates  the  corpus  luteum  and  this  stimulation  is 
lost  by  menstruation  then  placental  extract  by  inhibiting  men- 
struation allows  the  retained  decidual  secretion  to  continue 
its  stimulation  of  the  corpus  luteum.  If  we  knew  just  what 
elements  of  the  decidua  or  the  ovary  or  the  corpus  luteum 
or  the  pituitary  were  responsible  for  the  capillary  dilatation 
and  increased  tension  resulting  in  rhexis  and  diapedesis,  we 
would  find  them  antagonized  by  some  placental  ferment  or 
hormones  and  by  the  corpus  luteum. 

To  conclude  these  theoretical  considerations,  some  of 
which  are  being  proved  true,  it  may  be  stated  that  labor  rep- 
resents a  crisis  in  the  relation  among  the  glands  of  internal 
secretion,  particularly  the  ovary,  thyroid,  the  placenta,  and  the 
hypophysis.  On  the  two  hundred  and  eightieth  day  a  magnified 
menstruation  takes  place.  Placental  inhibition  is  overcome, 
the  ovaries,  so  to  speak,  come  into  their  own,  and  the  pos- 
terior pituitary  gland  exhibits  an  action  whose  character  is 
exemplified  by  and  intensified  by  the  pituitary  extract  which 
we  use  in  obstetrics.  If  placental  hormones  antagonize  or 
inhibit  the  menstrual  action  of  the  ovary  and  pituitary,  it 
is  probable  that  in  many  cases  this  inhibition  is  ineffectual. 
If  this  be  so  this  lack  of  power  in  the  placental  hormones  may 
explain  repeated  abortions  (Wassermann  negative)  occurring 


PREGXAXCY,    LABOR,    AND    THE    PLACENTAL   GLAND       207 

at  menstrual  intervals.  This  explains  the  well  known  liability 
to  abortion  at  periods  four,  eight,  twelve,  etc.,  weeks  after 
the  first  skipped  menstruation.  It  also  explains  the  tendency 
to  go  ten  or  more  days  "over  the  period"  with  a  then  ensuing 
menstruation.  These  occasional  occurrences  in  a  few  of  my 
patients  must  and  may  be  viewed  as  early  expulsions  of  an  im- 
bedded ovum  whose  trophoblast  secretion  has  not  inhibited  the 
menstrual  stimulus  of  ovary,  and  pituitary,  and  adrenals. 

Pituitrin  causes  rhythmical  contractions  of  the  uterus. 
The  effect  wears  off  quickly,  lasting  only  from  half  an  hour  to 
an  hour.  This  drug  is  probably  excreted  quickly  in  view  of  its 
well  known  action  on  the  kidneys.  The  amount  that  can  be 
given  by  mouth  and  by  injection  even  daily  is  decidedly 
evanescent  in  effect.  This  explains  my  incomplete  results  on 
continuing  its  use  even  daily  by  hypodermic  use  in  cases  of 
menorrhagia  or  metrorrhagia  unless  this  administration  is  pre- 
ceded by  a  thorough  curetting,  which  temporarily  inhibits 
ovarian  function.  It  compares  in  no  way  so  far  as  prolonged 
contraction  is  concerned  with  the  effect  of  ergotol  or  ergot. 
And  this  explains  the  value  of  ergotol  or  ernutin  by  mouth 
or  by  hypodermic  injection  in  the  postpartum  stage.  If  pitui- 
trin is  given  before  labor  is  completed,  it  causes  powerful  con- 
tractions of  the  uterus ;  it  also  causes  excessive  relaxation. 
This  accounts  for  the  rare  bleeding  effects  postpartum.  Hence 
ernutin,  or  aseptic  ergot  by  needle  or  ergotol  by  mouth,  are  the 
best  drugs  in  the  postpartum  stage,  and  this  may  explain 
why  with  its  use  postpartum  hemorrhage  is  rarely  noticed. 

From  these  considerations  we  pass  on  very  readily  to  the 
theory  of  eclampsia.  Logically  we  must  conclude  that  placen- 
tal secretion  is  the  important  factor.  It  does  not  produce  this 
annoyance  in  a  large  proportion  of  instances  because  some 
protective  substances  are  secreted  or  formed  anew.  They 
come  from  the  ovary  and  corpus  luteum,  from  the  thyroid 
and  adrenals,  from  the  hypophysis  gland,  from  the  liver,  and 
from  other  structures  in  the  body  not  yet  recognized  as  taking 
part  in  this  protective  function.  Then  come  a  certain  number 
of  cases  in  which  this  function  is  not  properly  carried  out  with 


208  THE    ENDOCRINES 

the  result  that  placental  secretion  exerts  a  decidedly  irritating 
influence.  Placental  secretion  is  a  substance  which  follows  the 
course  of  the  blood  into  all  the  organs  of  the  body,  producing 
changes  of  a  marked  character,  particularly  in  certain  instances 
in  the  liver  with  marked  alterations  of  metabolism.  These 
changes  are  of  a  necrotic  nature  and  of  a  hemorrhagic  type 
showing  the  irritating  nature  of  this  secretion.  If  the  usual 
protective  substances  are  lacking,  this  secretion  takes  on  an 
irritative,  destructive  nature.  The  changes  are  produced 
typically  in  the  brain,  microscopic  in  nature,  associated  oc- 
casionally with  hemorrhages  of  a  graver  type  and  with  edema 
more  or  less  diffuse  and  often  quite  marked  and  not  rarely 
associated  with  increased  pressure  in  the  spinal  canal.  Hence 
in  persistent  convulsions  and  especially  in  coma,  spinal  punc- 
ture should  be  tried  in  all  cases. 

The  kidney  annoyances  of  eclampsia  are  mainly  those 
due  to  the  excretion  through  these  organs  of  the  irritating 
placental  and  altered  metabolic  substances  which  irritate  the 
epithelium  and  produce  the  albumin  and  the  other  changes 
which  are  in  this  type  of  cases  an  evidence  of  the  toxemic  se- 
cretion in  the  blood.  With  a  normal  or  overactive  thyroid  such 
a  condition  is  less  likely. 

What  the  acidosis  and  diacetic  acid  are  due  to  we  need 
not  discuss  at  present,  but  in  this  metabolic  change  the  liver, 
in  all  probability  due  to  its  lesions,  takes  an  important  part. 
The  pancreas  must  likewise  be  considered. 

What  is  the  reason  for  this  possible  explanation  of  eclamp- 
sia? Let  me  refer  for  a  moment  to  hydatid  mole  and  to  chorio- 
epithelioma.  In  the  hydatid  mole  we  have  an  abnormal  myx- 
omatous development  of  the  chorionic  villi  with  an  unusual 
penetration  of  them  into  the  uterus  and  an  unusual  penetration 
of  those  cells  of  the  outer  layer  of  the  chorion. 

The  fact  that  the  cells  in  their  growth  and  invasion  are 
normally  held  in  check  is  evident.  As  soon  as  the  trophoblast 
cells  invade  the  capillaries  and  maternal  blood  is  poured  out, 
these  cells  change  to  the  so-caled  syncytium  cells.  These 
syncytium  cells  then  form  the  outer  covering  of  the  villi,  act- 


PREGNANCY,    LABOR,    AND    THE    PLACENTAL   GLAND       209 

ing  as  a  sort  of  endothelium,  and  through  them  and  the  cells 
underneath  them  the  exchange  between  maternal  blood  on  the 
one  hand  and  the  capillaries  in  the  villi  on  the  other  hand  takes 
place.  Therefore  in  the  blood  there  are  substances  which  in- 
hibit excessive  penetrative  action  of  these  cells  and  define 
the  degree  to  which  they  may  extend.  If,  then,  the  protec- 
tive substances,  especially  in  the  thyroid,  are  lacking,  one  would 
naturally  expect  an  unusual  development  of  the  chorionic  villi 
in  size  and  number,  and  also  an  unusually  deep  penetration  of 
the  syncytial  and  Langerhans  cells,  a  condition  which  actually 
takes  place.  This  need  not  be  surprising,  because  during  all 
the  months  of  pregnancy  the  syncytial  cells  and  fragments  of 
chorionic  villi  are  thrown  off  into  the  circulation  and  have 
been  found  in  the  various  structures  of  the  body.  They  nat- 
urally are  absorbed,  forming  a  secretion. 

Now  in  chorionic  epithelioma  the  same  thing  is  carried  to 
a  greater  degree.  We  have  no  dilatation  of  the  chorionic  villi, 
no  excessive  growth  of  them,  but  we  find,  several  weeks  or 
several  months  or  even  two  years  after  a  labor  or  an  abortion, 
certain  cells  of  the  chorionic  villi,  chorionic  syncytial  cells 
which  have  been  left  behind,  undergoing  independent  growth, 
developing  into  a  tumor,  spreading  through  the  blood  into  the 
neighboring  structures  and  into  other  parts  of  the  body.  Here 
it  is  evident  that  the  chorionic  cells  have  persisted  through 
various  periods  of  time,  not  alone  have  persisted  and  remained 
alive,  but  have  taken  on  a  sudden  growth  which  nothing  in 
the  maternal  blood  can  hold  in  check.  In  other  words,  the 
protective  influence  has  been  lost  or  some  endocrine  stimula- 
tion is  present   (post-pituitary). 

So  far  we  know  only  about  the  ovarian  lutein  cell  changes 
in  this  condition,  and  I  know  of  no  experiment  or  postmortem 
examination  made  upon  the  hypophysis  gland  or  other  gland 
structures  in  cases  of  this  type.  As  far  as  the  placenta  is  con- 
cerned we  may  certainly  say  that  the  ovum  is  a  parasite,  that 
the  trophoblast  cells,  syncytial  cells,  and  the  placenta  are  at 
all  times  held  in  check  in  normal  cases  by  certain  substances  in 
the  blood.      (Thyroid,  corpus  luteum.)     When  these  protec- 


210  THE    ENDOCRINES 

tive  substances  are  not  present  in  sufficient  quantity  in  the 
early  months,  the  expected  nausea  and  vomiting  occurs.  When 
they  are  not  held  in  check  in  the  later  months  either  a  yellow 
atrophy  or  the  toxemia  of  pregnancy  of  the  liver  or  kidney  type 
occurs,  and  in  other  instances  the  hydatid  mole  and  the  chorio- 
epithelioma. 

Whether  the  parathyroids  are  in  any  degree  concerned  in 
eclampsia  is  not  certain.  It  is  possible  that  mild  attacks  may 
simulate  the  type  of  tetany.  We  know  the  effect  of  calcium 
metabolism  on  the  general  nervous  system.  We  know  that  a 
normal  amount  of  calcium  is  necessary  to  preserve  a  sedate, 
stable  reaction  of  the  nerve  cells.  A  diminished  amount  of 
calcium  renders  them  extremely  susceptible  to  irritation.  The 
ovaries,  the  thymus,  the  parathyroids,  and  the  thyroid  are  in- 
timately concerned  with  calcium  metabolism,  and  during  preg- 
nancy the  functions  of  these  various  glands  may  be  so  altered, 
the  calcium  content  of  the  body  and  nerve  structures  may  be 
so  diminished  by  parathyroid  insufficiency,  that  we  have  in  this 
state,  generally  unrecognized,  an  increased  susceptibility  to 
irritating'  substances. 

It  is  the  preeclamptic  stage  to  which  especial  attention 
should  be  called.  We  find,  on  the  one  hand,  cases  with  marked 
involvement  of  the  renal  function  as  evidenced  by  albumin, 
casts,  and  occasionally  more  or  less  general  edema  (hypo- 
thyoridism).  We  find,  on  the  other  hand,  cases  with  digestive 
disturbances  and  headache,  dizziness,  excessive  irritability,  or 
the  contrary  type  of  mental  apathy  and  dullness  (post-pituitary 
plus).  High  blood  pressure  is  a  most  important  danger  sig- 
nal (thyroid  minus,  post-pituitary  plus).  No  man  should 
fail  to  pay  attention  to  conditions  where  the  urine  is  abnormal, 
especially  if  acetone  and  diacetic  acid  are  found.  Greater  and 
greater  significance  should  be  given  to  the  symptoms  of  nausea 
and  vomiting,  liver  tenderness,  headaches,  alteration  of  vision, 
dizziness,  high  blood  pressure,  and  allied  suggestive  symptoms. 

Wellbeing  is  a  sign,  as  a  rule,  of  absence  of  toxic  condi- 
tion. Whenever  a  woman  in  the  latter  weeks  of  pregnancy 
does  not  feel  well,  whatever  the  nature  of  the  symptoms,  a 


PREGNANCY,    LABOR,    AND    THE    PLACENTAL   GLAND       211 

preeclamptic  condition  should  be  constantly  considered  and 
considered  until  absolutely  excluded  by  a  decided  change  for 
the  better  in  the  patient's  general  condition, 

I  consider  a  great  amount  of  rest  in  the  latter  months 
of  pregnancy  a  most  important  factor.  I  do  not  believe  in  the 
theory  of  excessive  exercise  for  patients  who  are  pregnant. 
Plenty  of  fresh  air  and  normal  function  on  the  part  of  the 
kidneys  with  care  in  the  diet  are  important  in  every  case.  One 
of  the  greatest  improvements  in  the  field  of  obstetrics  is  the 
use  of  the  Murphy  drip.  I  feel  that  the  Murphy  drip  containing 
five  per  cent,  glucose  and  two  per  cent,  sodium  bicarbonate  the 
very  best  treatment  for  the  cases  of  early  toxemia  of  pregnancy 
and  especially  valuable  in  cases  showing  preeclamptic  symp- 
toms. In  eclampsia  I  consider  it  one  of  the  most  important 
methods  under  our  control.  I  think  the  acidosis  of  eclampsia 
or  in  the  eclamptic  or  the  preeclamptic  stage  of  great  im- 
portance as  a  dangerous  symptom  and  condition.  This  condi- 
tion should  be  combated  constantly  and  most  actively.  Per- 
sonally, I  consider  pituitrin  contraindicated  in  cases  of  high 
blood  tension  and  in  cases  showing  preeclamptic  symptoms, 
and  assuredly  in  eclampsia  occurring  during  labor.  It  causes 
powerful  uterine  contractions,  forces  placental  contents  into 
the  circulation,  and,  if  the  placenta  is  the  important  element 
in  this  toxemia,  puts  added  burden  on  the  liver  and  other 
glands  already  unable  to  overcome  the  toxins  in  the  blood. 
Excess  of  post-pituitary  with  its  action  on  the  kidneys  and  on 
the  choroid  plexus  of  the  cerebro-spinal  canal,  plus  hypothy- 
roidism are  the  important  causal  factors. 

Ca^sarean  section  is  to  my  mind  the  treatment  for  severe 
toxemia  and  eclampsia,  unless  the  patient  can  be  delivered  by 
forceps  without  great  effort  in  a  very  short  period  of  time. 

In  eclampsia  the  uterus  should  be  emptied  if  it  is  held 
that  the  placenta  bears  an  important  relation  to  the  develop- 
ment of  the  toxemia.  The  next  step  is  to  diminish  the  con- 
vulsions. The  third  step  is  to  aid  energetically  in  the  elimina- 
tion of  the  toxic  products  and  in  overcoming  the  acidosis.  It 
is  generally  agreed  that  the  uterus  should  be  emptied  quickly, 


212  THE    ENDOCRINES 

if  it  is  to  be  emptied  at  all,  and  emptied  in  a  manner  which 
affects  the  patient's  resistance  in  the  least  degree.  A  manual 
dilatation  of  the  rigid  cervix  of  a  primigravida  and  the  appli- 
cation of  forceps  or  the  practice  of  version  are  measures  which 
take  time  and  have  a  decided  effect  upon  the  patient's  re- 
sistance and  vitality.  They  likewise  jeopardize  the  welfare 
of  the  fetus.  These  babies  are  affected  by  the  toxemia  of  the 
mother  and  many  of  them  have  the  same  lesions  as  the  mother, 
many  of  them  have  convulsions,  and  many  of  them  die.  Any 
mode  of  delivery  which  makes  it  hard  and  difficult  for  the  baby 
jeopardizes  its  existence.  A  slow  method  of  dilatation  with  a 
bag  or  allowing  Nature  to  proceed  by  her  own  method,  a  de- 
livery going  along  several  hours,  even  if  uterine  contractions 
are  not  excessive  or  are  controlled  by  morphine,  is  certainly  a 
great  disadvantage  to  a  woman  in  convulsions.  Powerful 
uterine  contractions  with  expression  of  placental  secretion  into 
the  blood  and  liver  have  a  most  injurious  effect  on  the  toxemia. 
Of  course,  the  head  may  be  in  the  midplane,  the  cervix  may 
be  soft  and  readily  and  quickly  dilated.  Then  extraction  may 
be  done  readily  within  a  short  period  of  time  with  uterine 
contractions  excluded  by  morphine  and  the  anesthesia.  Here 
the  indications  are  fair  for  delivery  by  the  natural  route. 

Contrast  with  this  method,  however,  in  any  but  such 
favorable  cases,  the  operation  of  Caesarean  section.  To  make 
a  comparison,  I  believe  that  if  Caesarean  section  were  performed 
in  a  hundred  routine  cases  in  any  hospital  and  the  results  were 
compared  with  a  hundred  vaginal  operative  deliveries — the 
average  run  of  cases  with  high  or  low  forceps,  version,  etc. — 
we  would  find  everything  in  favor  of  Caesarean  section.  Prac- 
tically all  the  children  would  be  delivered  alive,  if  alive  at  the 
time  of  operation.  The  patient  takes  nitrous  oxide  and  slight 
ether  anesthesia,  the  operation  lasts  only  from  twenty  to  thirty 
minutes,  no  more  blood  is  lost  than  in  normal  delivery,  the  in- 
testines are  scarcely  touched,  and  convalescence  is  normal. 

On  the  other  hand,  in  a  hundred  routine  cases  of  heads 
not  firmly  engaged  in  the  brim  of  primigravidae  at  full  term 
where  forceps  are  often  used  or  where  version  must  be  done, 


PREGNANCY,    LABOR,    AND    THE    PLACENTAL   GLAND       213 

injuries  are  produced  in  the  cervix,  tears  and  lacerations  of 
the  perineum  occur,  and  a  goodly  proportion  of  the  patients 
have  to  have  an  operation  subsequently  for  relaxation  of  the 
bladder,  rectum,  and  the  pelvic  floor. 

In  preeclamptic  toxemia  and  in  eclampsia  the  same  prin- 
ciples hold  good.  The  anesthesia  afifects  the  patient  slightly; 
the  operation  is  done  quickly;  the  child  is  saved  without  any 
manipulation  or  any  injury  to  it,  and  if  it  has  any  chance  to 
live  at  all,  it  certainly  has  a  vastly  increased  chance  if  deliv- 
ered by  Csesarean  section.  Contrast  the  four  per  cent,  mortal- 
ity for  the  fetus,  mentioned  by  Peterson  in  the  Csesarean  sec- 
tion for  eclampsia,  with  the  thirty  to  forty  per  cent,  mortality 
when  delivered  by  the  normal  route,  and  no  further  discussion 
of  this  phase  of  the  question  is  needed.  Even  in  a  normal 
patient  with  a  fair  degree  of  difference  in  the  pelvic  measure- 
ments or  in  the  size  of  the  head,  we  do  a  Csesarean  section 
in  a  primigravida  to  make  certain  of  a  living  child.  This  holds 
good  in  a  double  degree  in  cases  of  severe  toxemia  or  in 
eclampsia.  To  summarize,  the  advantages  of  Csesarean  sec- 
tion are  rapid  delivery  and  the  removal  of  the  placenta  with  a 
minimum  of  shock  to  the  baby  and  the  mother,  the  delivery  of 
a  child  with  everything  in  favor  of  its  remaining  alive  and 
well,  and  absence  of  injury  to  the  pelvic  structures.  Surely 
these  advantages  are  sufficient  to  point  to  Caesarean  section 
as  the  more  advisable  routine  method.  Most  important  of  all 
we  avoid  the  uterine  contractions  of  labor.  Even  if  a  certain 
proportion  of  cases  of  eclampsia  are  not  of  a  severe  type,  one 
can  never  tell  after  the  first  few  convulsions,  whether  coma 
will  intervene.  Many  of  the  patients  have  a  profound  in- 
volvement of  the  kidney,  as  evidenced  by  albumin,  casts,  red 
blood  cells,  etc.  A  decided  acidosis  may  develop.  These  cases 
probably  are  of  both  the  renal  and  liver  type,  and  even  if  one 
may  argue  that  patients  w^ould  have  survived  with  normal  route 
delivery  from  below,  surely  their  welfare  is  in  no  sense  jeop- 
ardized by  Csesarean  section.  And  many  of  these  patients  do 
manifest  the  severest  form  of  convulsions,  often  with  coma. 
I  believe  that  the  routine  administration  of  thyroid  extract 


214  THE    ENDOCRINES 

from  the  moment  that  albumin  or  casts  appear,  or  from  the 
moment  that  the  blood  pressure  rises,  and  then  continued  for 
the  duration  of  pregnancy  will  prove  to  be  a  boon  to  the  field 
of  obstetrics. 

Toxemia  patients,  the  so-called  preeclamptics,  may  have 
convulsions  in  labor  induced  or  coming  on  without  help.  And 
when  we  come  to  the  more  severe  type,  the  so-called  liver  type, 
rapid  emptying  of  the  uterus  is  necessary,  for  it  is  not  alone 
the  emptying  of  the  uterus  that  will  cure  the  patient,  it  is  the 
subsequent  treatment  which  is  necessary  and  that  is  certainly 
possible  only  with  an  empty  uterus. 

Convulsions  must  be  diminished  by  every  possible  means. 
A  convulsive  attack  of  a  severe  nature  repeated  at  frequent 
intervals  is  a  tremendous  strain  on  the  patient  and  is  a  tre- 
mendous strain  on  the  heart.  Many  of  these  patients  die  of 
edema  of  the  lungs.  Each  successive  attack  with  a  convulsion, 
the  rise  in  tension,  the  strain  on  the  heart,  and  the  interference 
with  respiration,  affects  the  degree  of  resistance  profoundly 
and  certainly  often  causes  an  edema  of  the  lungs  and  brain 
and  disturbance  of  the  spinal  structures.  This  edema  of  the 
brain  is  undoubtedly  responsible  in  many  cases  for  the  coma 
of  a  profound  type.  The  role  of  the  post-pituitary  in  this 
condition  and  in  affecting  the  osmosis  of  the  cerebro-spinal 
fluid  through  the  choroid  plexus  is  the  special  point  of  im- 
portance. 

I  find  morphine  the  best  drug  for  convulsions.  Even  if 
it  does  in  a  slight  degree  interfere  with  elimination  by  the  kid- 
neys, this  disadvantage  is  not  great.  In  addition,  we  know 
of  no  better  treatment  for  threatened  edema  of  the  lungs  than 
the  use  of  morphine.  In  some  of  these  cases  of  profound  coma, 
it  has  been  found  that  a  spinal  puncture  is  a  lifesaving  meas- 
ure; and  it  should  be  attempted  in  every  case,  and  if  an  in- 
crease of  fluid  under  great  pressure  is  found,  it  should  be  re- 
peated whenever  the  indication  demands  it.  If  the  fluid-extract 
of  veratrum  viride,  given  repeatedly  in  small  doses,  diminishes 
the  blood  pressure,  the  pulse  rate  and  the  convulsions,  well  and 


PREGNANCY,    LABOR,    AND    THE   PLACENTAL   GLAND       215 

good.    In  my  hands  I  have  found  morphine  when  indicated  the 
more  rehable  drug  for  this  last  purpose. 

The  next  step  demands  the  ehmination  of  the  toxic  prod- 
ucts and  the  combating  of  the  acidosis,  which  is  of  utmost 
importance.  High  colonic  irrigations  are  necessary.  It  is 
wise  to  use  an  alkaline  fluid,  either  bicarbonate  of  soda  or 
acetate  of  potash,  very  warm.  Gallons  should  be  used,  not 
quarts.  Irrigations  should  last  half  an  hour  and  from  ten  to 
fifteen  gallons  should  be  used.  This  should  be  repeated  two 
or  three  times  in  twenty-four  hours.  If  the  colon  is  tolerant 
between  these  irrigations  a  continuous  Murphy  drip  of  five 
per  cent,  glucose  and  a  two  per  cent,  bicarbonate  of  soda  should 
be  administered.  The  purpose  of  the  colon  is  particularly  to 
absorb  fluid  as  well  as  to  excrete,  as  far  as  we  know  at  least. 
Hence  high  colonic  irrigations  with  an  alkaline  medium  prob- 
ably will  help  in  absorbing  into  the  body  a  fluid  of  an  alkaline 
nature  which  not  alone  neutralizes  the  acidosis  but  dilutes  the 
toxins  and  promotes  diuresis. 

Venesection  is  highly  praised  by  some  men,  and  with  a 
high  blood  pressure  and  a  full  pulse  it  may  be  indicated,  300 
to  500  c,  c.  being  taken.  Whether  it  is  advisable  to  substitute 
this  by  the  injection  into  the  blood  of  any  fluid  or  human  blood 
is  a  question,  I  rather  fear  a  saline  infusion  afterward  if  the 
blood  pressure  remains  high,  for,  having  drawn  off  the  blood, 
the  labor  of  the  heart  is  diminished,  and  if  a  large  amount  of 
saline  is  injected  in  place  of  the  removed  blood,  we  may  pro- 
mote an  edema,  which  is  the  one  thing  which  must  be  avoided. 

The  overcoming  of  the  acidosis  is  of  the  utmost  im- 
portance no  matter  what  the  condition  of  the  kidneys  may  be, 
and  no  matter  how  little  they  may  be  secreting  with  or  without 
decided  amounts  of  albumin  and  casts.  The  acidosis  is  of  the 
utmost  danger.  Hence  I  repeat  that  the  high  colonic  irrigation 
should  be  of  an  alkaline  nature  and  the  Murphy  drip  should 
contain  glucose  and  an  alkali.  In  the  acidosis  a  deficiency  of 
carbohydrates  is  concerned,  and  if  we  supply  sugar  to  the  body 
by  absorption  through  the  colon,  and  at  the  same  time  use 


216  THE    ENDOCRINES 

either  bicarbonate  of  soda  or  acetate  of  potash,  we  are  doing 
all  that  we  know  to  overcome  this  destructive  process. 

The  feeding  of  a  patient,  if  coma  lasts,  is  of  greatest  im- 
portance, not  alone  to  sustain  the  existence  of  the  patient,  but 
to  aid  in  overcoming  the  acidosis,  for  the  starvation  certainly 
adds  to  this  state.  Hence  patients  should  be  fed  at  regular 
intervals  by  the  stomach  tube  if  in  coma,  peptomized  m^lk  being 
of  the  very  best  aid.    Bicarbonate  of  soda  may  be  added  to  this. 

I  wish  to  mention  an  interesting  case : 

Case. — The  patient  went  into  coma  forty-eight  hours 
after  the  first  convulsion,  which  occurred  six  hours  after  her 
delivery.  Labor  was  induced  because  of  the  preeclamptic 
symptoms  associated  with  a  marked  nephritic  stage.  Chloral 
and  bromides  by  rectum  and  morphine,  however,  controlled  the 
convulsions.  On  the  fifth  day  she  manifested  a  decided  in- 
terference with  her  respirations,  showing  a  Cheyne-Stokes 
type.  A  spinal  puncture  was  done  and  the  fluid  shot  out  under 
great  pressure  and  large  amounts  were  withdrawn.  Within 
five  minutes  her  breathing  became  perfectly  normal.  The  spinal 
puncture  was  repeated  on  two  successive  occasions. 

I  believe  this  patient's  life  was  saved  by  the  spinal  punc- 
tures. This  has  taught  me  to  view  every  case  of  coma  follow- 
ing toxemia  or- eclampsia  as  possibly  due  to  cerebrospinal  pres- 
sure. Spinal  puncture  should  be  done  if  only  for  diagnosis. 
There  is  certainly  no  difficulty  and  no  danger  to  the  patient, 
and  there  is  a  hope  that  it  may  save  life. 

Reviewing  the  questions  discussed  in  this  chapter,  I  can 
only  emphasize  my  opinion  that,  based  on  logic,  theory,  and 
the  statistics  of  Peterson,  abdominal  Csesarean  section  at  or 
near  full  term  is  the  method  for  eclampsia  and  for  toxemia  of 
severe  type.  I  feel  that  much  can  be  done  in  a  proper  study  of 
patients  during  the  last  four  or  five  weeks  of  pregnancy.  At- 
tention must  be  paid  to  the  blood  pressure,  examination  for 
acidosis,  examination  for  albumin  and  casts,  subjective  symp- 
toms such  as  headache,  dizziness,  nausea,  vomiting,  mental  dull- 
ness, a  change  in  disposition,  all  of  which  should  be  looked  for 
in  every  case,  and  when  present  should  be  considered  preeclamp- 


PREGNANCY,    LABOR,    AND    THE   PLACENTAL   GLAND       217 

tic  and  signs  of  excessive  clanger.  High  blood  pressure  is  of 
grave  significance.  Thyroid  extract  should  be  given  in  all 
cases.  If  the  child  is  viable,  safe  delivery  should  be  the 
procedure.  If  delivery  can  be  rapidly  followed  out  by  the 
normal  route  without  labor  pains,  well  and  good;  if  not, 
Caesarean  section  should  be  done.  Theoretically  corpus  lu- 
teum  which  stimulates  the  thyroid  and  inhibits  the  post-pitui- 
tary should  be  valuable.  Thyroid  extract  to  lower  blood  pres- 
sure and  prevent  swelling  of  the  renal  epithelium  is  indicated 
throughout  pregnancy  in  many  cases.  Placental  extract  may 
some  day  be  used  to  inhibit  if  possible  the  post-pituitary.  The 
placenta,  which  is  probably  responsible  for  the  toxemia  of  preg- 
nancy, is  developed  partly  from  the  spermatozoa  contributed 
by  the  partner.  This  condition  may  possibly,  therefore,  be 
allied  to  anaphylaxis. 


CHAPTER    XI 
CONSTITUTIONAL  DYSMENORRHEA 

The  idea  that  the  ovaries,  by  reflex  nerve  stimulus,  are 
responsible  for  menstruation  is  old  and  no  longer  held.  Men- 
struation results  because  no  fecundated  ovum  takes  its  place 
within  the  uterus  after  the  ovarian  secretion  has  caused  a 
thickening  of  the  mucosa  in  preparation  for  the  nidation  of 
the  ovum.  As  a  result  of  menstruation  the  mucous  membrane 
goes  back  to  its  former  size  and  state,  and  a  few  days  before 
the  next  awaited  period  undergoes,  as  a  result  of  ovarian  secre- 
tion, the  same  changes  in  preparation  for  nidation. 

These  local  phenomena,  resulting  through  the  selective 
action  of  the  ovarian  secretion,  are  associated  with  phenomena 
in  other  parts  of  the  body,  resulting  from  or  roused  by  the 
ovarian  secretion  and  other  hormones  stimulated  by  the  ovaries. 
These  phenomena  produced  by  the  ovarian  secretion  partake  of 
the  nature  of  congestion  and  hyperemia,  with  increase  of  vas- 
cular tension,  affecting  particularly  mucous  and  serous  mem- 
branes and  the  endocrine  glands  and  glandular  structures  of 
the  body. 

There  is  an  increase  in  the  blood-pressure  seven  to  ten 
days  before  menstruation.  Patients  often  complain  of  head- 
ache, colicky  pains  in  the  abdomen,  drawing  pains  in  the  back 
and  pelvis  down  into  the  thighs.  In  a  nervous  patient  uterine 
contractions  may  increase  up  to  the  degree  of  spasticity,  result- 
ing in  dysmenorrhea,  evidently  associated  with  an  existing 
hypersensibility.  Menstruation  may  affect  the  eye  and  lids  in 
many  ways;  may  affect  the  ear,  the  digestive  tract,  larynx. 
There  may  be  periodic  toothache,  labial  herpes,  stomach  pain, 
loss  of  appetite.  The  premenstruated  period  has  a  bad  effect 
on  ulcer  of  the  stomach.  The  skin  changes  are  frequent,  such 
as  chloasma,  erythema,  eczema,  urticaria,  nervous  skin  swell- 
ings, etc. 

Involved  in  this  constitutional  reaction,  ofttimes  visibly 
involved,  is  the  thyroid  gland.     It  is  a-  matter  of  common  ob- 

218 


CONSTITUTIONAL    DYSMENORRHEA  219 

servation  that  the  neck  enlarges  and  the  thyroid  swells  during 
menstruation  and  during  the  early  months  of  pregnancy.  In 
pregnancy  we  have,  as  causative  factors,  the  true  corpus  lu- 
teum  and  the  trophoblast ;  in  the  premenstrual  period  we  have 
only  the  ovarian  secretion,  that  produced  by  the  follicles  and 
false  corpus  luteum  and  the  intestitial  gland,  the  former  stimu- 
lating the  glandular  thyroid.  This  idea  of  interrelation  and 
antagonism  between  ovary  and  thyroid  appears  to  be  generally 
accepted ;  they  stimulate  each  other,  and,  at  the  same  time,  are 
probably  antagonistic. 

The  reaction  of  the  individual's  endocrines  to  the  pre- 
menstrual cumulative  influence  of  the  ovarian  secretion  fol- 
lows different  types — some  patients  do  not  know  from  any 
symptoms  at  all  that  menstruation  is  approaching ;  others  show 
the  local  pelvic  phenomena  of  congestion,  discomfort,  or  pain ; 
others  have  a  constitutional  alteration,  characterized  by  a  dull, 
heavy,  tired  feeling;  a  goodly  proportion  show  symptoms  of 
irritation,  and  constitute  the  excitable  type.  The  reasons  for 
these  different  types  are  to  be  found,  naturally  of  course,  in 
the  character  of  the  ovarian  secretion,  its  stimulation  of  other 
secretions,  and  in  the  sensitiveness  of  the  organism  that  is 
being  played  upon,  so  to  speak.  In  some  patients  there  is  very 
little  constitutional  congestion  produced  by  ovarian  secretion, 
and  very  little  alteration  in  any  of  the  mucous  or  serous  mem- 
branes ;  other  individuals  are  possessed  of  a  placid,  nervous 
system,  in  many  ways  almost  insensitive  to  such  changes.  In 
certain  women  the  thyroid  is  scarcely  stimulated  by  the  ovarian 
secretion,  or  reacts  too  slightly,  if  at  all,  to  its  cumulative  in- 
fluence; in  others,  the  faintest  beginning  of  ovarian  premen- 
strual activity  is  immediately  followed  by  a  response  of  the 
thyroid,  in  the  form  of  actual  or  relative  over-activity,  and  the 
same  holds  true  of  the  pituitary  and  the  adrenals. 

The  reaction  of  an  individual  to  the  premenstrual  phase 
is  a  fairly  good  indication  of  the  sensitiveness  of  that  patient's 
nervous  organization  at  that  particular  age,  or  of  the  stability 
of  that  patient's  endocrine  system.  Whether  this  is  due  to 
either  of  the  two  gradations,  too  much  ovary  or  too  much  or 


220  THE    ENDOCRINES 

too  little  thyroid,  pituitary  or  adrenal  secretion  it  is  an  index 
of  considerable  importance. 

Some  severe  cases  of  premenstrual  constitutional  annoy- 
ances are  found  in  what  might  be  called  "nervous,"  "neurotic," 
or  "neurasthenic"  individuals,  and  this  "nervousness"  is  in 
many  cases  nothing  other  than  hyperthyroidism  or  hyperadre- 
nalism  or  hyperpituitarism,  evident,  too,  in  the  intermenstrual 
periods.  We  are  concerned  also  with  that  type  which  is  rela- 
tively free,  in  the  intermenstrual  periods,  from  "nervous" 
symptoms. 

Preceding  the  menopause  age  and  stage,  instances  of  con- 
stitutional dysmenorrhea  become  rather  frequent.  We  have 
the  types  of  cases  in  which  the  annoyances  were  present  to  a 
greater  or  lesser  extent  for  years  from  puberty  on,  or  else  de- 
veloped at  a  later  period,  or  came  on  after  marriage,  or  were~ 
aggravated  by  various  circumstances.  Then  comes  another  and 
important  type,  the  cases  into  whose  histories  these  annoy- 
ances come  as  a  new  process.  These  patients  in  their  earlier 
years  had  slight,  if  any,  premenstrual  annoyances.  As  they 
approach  the  period  of  life  when  they  look  forward  to  the 
menopause  their  menstruation  continues,  even  grows  stronger, 
with  or  without  intervals  of  amenorrhea,  and  marked  cyclic 
states  of  irritability  appear.  These  cases  are,  in  a  large  number 
of  instances,  hyperpituitarism  or  hyperthyroidism;  some  of 
them  are  cases  of  actual  or  relative  hypothyroidism,  for  we 
find  instances  of  the  very  opposite  type,  too,  where  a  phleg- 
matic and  depressed  state  results,  a  condition  often  due  to 
hypothyroidism.  The  cause  of  this  dysthryroidism  lies  in  the 
thyroid  and  ovaries.  Either  the  latter  functionate  with 
marked  energy,  or  overshadow  the  thyroid  activity,  or  they 
actually  overstimulate  and  rouse  the  thyroid  gland,  or  else  they 
work  with  less  than  their  former  power,  but  the  thyroid  fails 
to  regress  with  equal  degree,  and  a  state  of  cyclic  hyperthyroid- 
ism results,  and  the  same  holds  true  with  the  pituitary  and  the 
adrenals  and  other  glands. 

The  administration  of  thyroid  gland  extract  between  men- 
strual periods  and  before  menstrual  periods,  serves  to  aid  in 


CONSTITUTIONAL    DYSMENORRHEA  221 

making  the.  diagnosis.  In  the  hyperthyroid  cases  the  premen- 
strual annoyances  are  brought  out  in  the  intervals,  or  are 
brought  on  earlier,  or  are  accentuated  by  the  administration 
of  thyroid  extract.  Among  the  medical  methods,  preparations 
of  bromides,  and  of  veronal  and  ovarian  extract,  ovarian 
residue,  and  suprarenal  extract,  help  to  diminish  the  annoy- 
ances. In  the  hypothyroid  or  hyperovarian  type,  doses  of 
thyroid  are  of  value.  In  the  hyperpituitary  form,  placental 
extract  and  thyroid  extract  are  indicated,  especially  if  the  blood 
pressure  is  high  or  is  increased  at  the  premenstrual  period.  In 
some  of  the  hyperthyroid  cases  small  doses  of  opium  and 
belladonna  in  suppositories  are  absolutely  necessary  to  give 
the  patient  relief,  not  so  much  from  their  pain  and  discomfort 
as  from  the  irritability  and  ofttimes  almost  maniacal  restless- 
ness which  typifies  these  hyperthyroid  cases.  In  the  hypothy- 
roid form,  or  hyperovarian  type,  thyroid  should  be  given.  Hy- 
peractivity of  the  adrenal  medulla,  hyperactivity  of  the  pos- 
terior pituitary^  are  frequently  associated.  This  hyperactivity 
of  the  adrenal  medulla  often  accompanies  hyperthroidism  and 
is  generally  associated  with  all  the  severe  forms  of  hyper- 
thyroidism. I  believe  that  overactivity  of  the  posterior  pitui- 
tary is  the  cause  of  exaphthalmos  and  it  is  often  associated 
with  hyperthyroidism. 

The  fact  that  patients  who  have  never  had  these  annoy- 
ances in  their  earlier  years,  and  that  patients  who  evidence  at 
times  the  symptoms  of  myxedema,  acquire  at  later  periods,  and 
most  particularly  in  the  preclimacteric  stage,  these  constitu- 
tional nervous  phenomena,  shows  that  at  that  period  there  is 
decided  susceptibility  to  alterations  in  the  balance  between 
thyroid  and  ovaries.  This  lack  of  balance  between  thyroid 
and  ovarian  secretion,  and  probably  in  very  many  instances 
a  malrelation  between  other  glands,  especially  the  hypophysis 
and  adrenals,  is  of  great  importance.  Too  much  ovarian  se- 
cretion can  cause  congestive  symptoms  associated  with  irri- 
tability. It  is  common  knowledge  that  the  change  of  life,  as 
the  laity  call  it,  is  a  critical  period.  It  is  not  sufficiently  recog- 
nized that  each  premenstrual  period  is  often  quite  as  critical. 


222  THE    ENDOCRINES 

Are  these  cyclic  annoyances  to  be  explained  simply  on  the 
theory  of  congestion  and  increased  tension  produced  by  the 
ovarian  secretion,  or  do  other  elements,  influenced  by  the 
ovarian  hormones  and  by  the  corpus  luteum,  play  an  important 
part? 

The  change  in  gland  relations  which  occurs  at  puberty, 
at  which  time  minor  thyroid  annoyances  are  frequent,  the  thy- 
roid phenomena  at  menstruation,  during  pregnancy,  in  asso- 
ciation with  ovarian  affections,  and  during  the  climacterium, 
find  a  parallel  in  the  fact  that  the  more  typical  diseases  of  the 
thyroid,  myxedema  and  Basedow's  diseases,  are  eight  to  ten 
times  as  frequent  in  women  as  in  men.  No  satisfactory  ex- 
planation for  this  has  yet  been  given.  It  always  seemed  to 
me  plausible  that  the  instability  of  the  relation  which  the  thy- 
roid bears  to  the  ovaries  and  uterus,  the  monthly  menstrua- 
tion, the  presence  of  the  corpus  luteum,  etc.,  makes  the  thyroid 
surely  more  susceptible  to  the  intercurrent  causes,  whatever 
these  may  be,  which  produce  these  same  diseases  in  a  far 
smaller  proportion  in  men.  In  women  the  glandular  thyroid 
acts  more  than  does  the  interstitial. 

The  monthly  play  produced  on  a  woman's  nervous  sys- 
tem by  the  premenstrual  ovarian  stimulation  causes,  either  of 
itself  or,  in  many  cases  through  an  exaggerated  response  on 
the  part  of  the  thyroid,  posterior  pituitary  and  other  glands  at 
these  times,  a  group  of  nerve  phenomena  like  those  in  hyper- 
thyroidism and  hyperpituitarism  and  hyperadrenalism,  to 
which  may  be  given  the  term  constitutional  dysmenorrhea. 

Some  patients  are  depressed  almost  to  the  verge  of  melan- 
choly before  each  menstruation.  They  are  sluggish  in  thought, 
indifferent  to  their  surroundings.  There  is  a  mental  inertia, 
they  are  inclined  to  be  sleepy  and  drowsy,  and  awake  without 
a  sense  of  well-being.  Pulse  is  slow,  there  is  a  sensation  of 
cold.  They  constitute  the  phlegmatic  type,  and  are  the  oppo- 
site of  the  type  to  which  I  desire  particularly  to  draw  attention 
as  the  more  frequent. 

There  is  in  this  other  and  important  class  of  patients  a 
nervous  excitability  in  the  premenstrual  phase,  an  irritability, 


CONSTITUTIONAL    DYSMENORRHEA  223 

and  a  restlessness  that  is  almost  maniacal.  The  patients  can- 
not keep  quiet,  find  it  impossible  to  lie  down  or  rest,  are  un- 
able to  keep  their  minds  on  any  one  subject.  They  have  not 
the  patience  to  take  part  in  conversation,  or  to  listen  to  any 
talk  or  information.  They  realize  that  their  train  of  thought 
is  unusual.  They  have  a  sense  of  heat,  and  complain  of  burn- 
ing sensations.  There  is  a  tremor  about  the  hands,  and  the 
knee-jerks  are  exaggerated.  They  sleep  badly,  and  have  a 
pulse  of  90  or  more.  (Hyperpituitarism,  hyperadrenalism, 
hyperthyroidism. ) 

There  is  another  class  of  patients,  in  whom  there  is  a  play 
between  hypothyroidism  and  hyperthyroidism.  The  symptoms 
of  hypothyroidism  may  seem  to  be  manifest  between  menstrua- 
tion, only  to  be  changed  to  the  type  of  hyperthyroidism  before 
and  during  menstruation.  We  must  dissociate  that  type  suf- 
fering from  well-marked  annoyances  of  probable  hyperthy- 
roidism at  all  times  from  the  type  where  the  hyperthyroidism 
is  characterized  by  its  premenstrual  periodicity. 

Mild  forms  of  hypothyroidism,  which  are  called  "neuras- 
thenia," are  very  frequent.  On  the  other  hand,  in  "neuras- 
thenics" there  is  overactivity  of  the  thyroid.  Just  as  the  larger 
number  of  cases  of  hyperthyroidism  are  transient,  and  recover 
rapidly  with  appropriate  medication,  so  many  of  these  cases 
of  so-called  constitutional  dysmenorrhea  are  cyclic  hyperthy- 
roidism, hyperpituitarism,  hyperadrenalism,  and  may  be  bene- 
fited or  cured. 

It  must  be  remembered  that  various  emotions  and  mental 
stimulation  rouse  the  thyroid,  pituitary  and  adrenals  to  activity. 
The  same  is  true  in  the  sexual  sphere,  and  holds  good  for 
some  of  the  diseases  of  the  genitalia.  Alcohol,  coffee,  tea, 
iodids,  and  arsenic  stimulate  the  thyroid.  The  endocrines  are 
quieted  by  rest,  freedom  from  sexual  stimulation,  and  by  the 
correction  of  pelvic  congestion  and  pelvic  pains.  A  milk  diet, 
the  glycerophosphates,  ergot,  and  especially  the  bromids, 
opium,  and  belladonna,  are  of  great  service.  In  most  cases 
ovarin  and  ovarin  residue  and  placental  extract  work  best  of  all. 


224  THE,    ENDOCRINES 

The  uterine  lining  is  acted  on  by  the  ovaries,  probably  by 
the  follicle  secretion.  Some  of  the  cyclic  phenomena,  oc- 
curring in  the  uterus  as  part  of  the  normal  process  called  men- 
struation, are  due  to  the  interstitial  gland.  The  uterine  lining 
reacts  on  the  ovaries,  too,  for,  if  the  uterus  is  removed,  ovarian 
secretion  gradually  diminishes  and  ofttimes  ceases  long  before 
the  end  of  two  years.  The  lining  of  the  cervix  and  uterus  and 
their  hormones  react  on  the  ovaries.  When  a  fecundated  ovum 
is  present,  it  stimulates  the  ovary  to  the  production  of  a  true 
corpus  luteum,  and  this  corpus  luteum  still  further  stimulates 
the  decidua  and  uterine  growth.  We  are  certain  that  the  re- 
lation of  the  thyroid  to  the  ovary,  to  its  follicular  apparatus  and 
to  the  corpus  luteum  sensitizes  the  thyroid  gland,  and  that  the 
relation  between  the  uterine  lining  and  the  ovary  sensitizes  the 
ovary. 

If  we  remove  the  endometrium,  we  take  away  one  of  the 
elements  which  react  on  the  ovary.  If  we  can  make  these 
patients  cease  menstruating  and  leave  the  ovaries  behind,  the 
oversecretion  of  the  ovaries  and  the  cyclic  response  of  the  thy- 
roid and  the  pituitary  seem  to  be  markedly  weakened  and  usu- 
ally removed,  and  the  reaction  of  the  ovaries  to  the  endometri- 
cal  hormones  is  done  away  with.  I  know  only  one  way  of  pre- 
serving the  ovaries,  for  a  time  at  least,  and  putting  a  stop  to 
menstruation,  and  that  is  to  remove  the  uterus.  My  list  of 
operative  cases  of  this  type  at  present  is  not  large  enough  to  go 
into  an  extensive  discussion  of  the  subject.  I  am,  with  each 
year,  more  and  more  convinced  that  hysterectomy,  especially 
vaginal  hyserectomy,  whenever  possible,  offers,  in  a  large  num- 
ber of  such  cases,  relief  from  annoyances  which  not  infre- 
quently persist  for  years,  and  which  may  bring  patients,  to  say 
the  least,  to  the  verge  of  invalidism.  I  can  see  no  theoretic 
objection  to  the  procedure.  It  spares  the  patient  the  oft-asso- 
ciated loss  of  large  amounts  of  blood  which,  in  itself,  Is  a  factor 
worthy  of  consideration. 

In  hundreds  of  cases  of  real  hyperthyroidism  the  thyroid 
is  removed  in  part,  or  its  blood-supply  is  diminished  by  opera- 
tive procedure,  when  the  indication  Is  by  no  means  one  of  life 


CONSTITUTIONAL    DYSMENORRHEA  225 

and  death  but  only  one  of  comfort.  Why  should  not  the  same 
view  of  eventual  surgical  relief  hold  good  in  the  type  of  con- 
stitutional dysmenorrhea  which  I  have  mentioned  ? 

This  type  of  cases  referred  to  here  cannot  be  properly 
studied  or  appreciated  in  dispensary  practice.  They  seem  to 
affect  patients  in  the  higher  spheres  of  life,  and  require  long- 
continued  observation  to  thoroughly  understand  the  type  of 
annoyances,  to  make  the  diagnosis  by  observation  and  by  the 
use  of  thyroid,  placental  extract,  suprarenal  extract;  to  see 
the  effects  and  improvements  obtained  by  local  treatment,  the 
use  of  ovarian  extract,  suprarenal  extract,  placental  extract, 
etc.,  and  the  elimination  of  psychic  irritations. 

It  has  been  said  that  no  uterine  hormone  has  ever  been 
demonstrated.  It  is  impossible  to  confine  ourselves,  in  a  the- 
oretic argument,  or  attempt  to  come  to  a  logical  conclusion,  to 
facts  absolutely  demonstrated  in  the  laboratory  or  by  animal  ex- 
perimentation. Besides,  there  are  hormones  which  produce  an 
immediate  result,  such  as  adrenalin,  pituitrin,  or  which  give  a 
quick  response  within  a  few  days,  such  as  thyroid.  The  ovarian 
hormones  and  the  uterine  hormones  do  not  act  so  promptly, 
even  when  both  ovaries  are  working  in  the  human  economy; 
it  takes  them  twenty-eight  days  to  produce  their  cyclic  uterine 
alterations,  and  if  the  hormones  of  the  uterus  do  respond  and 
react  on  the  ovary  it  is  probably  only  an  activation  of  the 
ovarian  secretory  function,  all  of  which  are  points  which  animal 
experimentation  or  human  observation  can  clear  up  with  dif- 
ficulty in  such  a  direct  and  rapid  manner  as  to  prove  that  these 
hormones  do  exist.  Besides,  the  ovary  possibly  possesses  other 
hormones  than  the  products  of  the  follicles  or  luteum  secretion 
(interstitial  gland). 

A  point  of  great  importance  is  the  answer  to  the  ques- 
tion, why  does  ovarian  secretory  activity  diminish  after  re- 
moval of  the  uterus?  Now,  it  is  a  fact  that  scarcely  a  single 
secretory  gland  can  be  removed  experimentally,  in  whole  or  in 
part,  without  involving  the  other  glands  of  the  body  in  the 
way  of  hypertrophy  or  atrophy.  This  interrelation  between 
the  glands  is  very  complicated.     If  removal  of  the  uterus,  and 


226  THE    ENDOCRINES 

with  it  its  lining,  does  produce  such  a .  result  in  the  ovaries, 
then,  whether  uterine  hormones  have  been  demonstrated  or 
not,  it  must  be  apparent  that  a  failure  of  the  uterine  elements 
to  react  on  the  ovaries  deprives  the  ovaries  of  a  certain  stimulus 
which  keeps  up  or  activates  their  function. 

If  a  too  thorough  curettage  be  done,  or  if  any  intra- 
uterine manipulation  be  carried  out  which  ends  in  a  cessa- 
tion of  menstruation,  and  gradual,  temporary,  or  perma- 
nent amenorrhea,  why  haven't  we  the  right  to  say  that  some- 
thing has  been  removed  from  the  uterus  which  has  a  stimulating 
action  on  the  ovary,  the  ovary  underfunctionates,  fails  to  re- 
stimulate  the  uterus  sufficiently,  and  by  this  diminution  of 
interaction  ovarian  and  uterine  atrophy  results?  The  same 
idea  holds  good,  in  all  probability,  in  lactation  atrophy  as  a 
result  of  mammary  secretion. 

Though  it  is  true  that  the  thyroid  is  the  cause  of  many  of 
these  annoyances,  the  hypophysis  plays  a  most  important  part. 
So  do  the  adrenals.  No  one  can  deny  the  importance  of  the 
hypophysis.  In  childhood  it  is  an  important  factor  in  promot- 
ing growth,  and  lack  of  it  inhibits  development,  both  of  the 
body  and  the  genitalia.  In  adult  life  too  much  hypophysis 
causes  acromegaly;  too  little  hypophysis  causes  dystrophia. 
The  hypophysis  is  intimately  connected  with  the  development 
of  the  sexual  apparatus.  Its  influence  is  altered  during  preg- 
nancy, but  all  these  changes  are  of  a  slower  type;  they  take 
weeks  or  months  to  produce  their  pregnancy  annoyances.  Yet 
the  posterior  pituitary  and  the  adrenals  take  part  in  the  month- 
ly cyclic  changes.  The  ovary  and  its  relation  to  the  thyroid, 
pituitary  and  adrenals  represent  an  apparatus  in  a  continual 
state  of  changeable  relation,  and  that  changeable  relation  is 
cyclic,  and  is  one  of  the  responsible  factors  in  making  women 
the  "weaker  sex."  Why  is  it  universally  recognized  that  the 
thyroid  has  a  most  intimate  relation  to  the  genitalia;  it  is 
practically  a  sex  gland.  There  are  well-defined  symptoms 
for  hyperthyroidism  and  hpothyroidism.  In  oversecretlon 
of  the  thyroid  we  have  the  greatest  variations  from  typical 
cases  of  exophthalmic  goiter  to  cases  without  the  exophthal- 


CONSTITUTIONAL    DYSMENORRHEA  227 

mos,  without  the  marked  goiter,  without  the  tremendous 
tachycardia,  down  to  the  forms  characterized  by  nervous  ir- 
ritabihty,  by  digestive  annoyance  and  only  moderate  degrees 
of  tachycardia.  Some  of  these  eventually  develop  symptoms 
which  makes  the  diagnosis  absolutely  certain,  others  improve 
so  rapidly  that  our  first  diagnosis  seems  afterward  to  have 
been  only  a  suspicion.  Many  of  the  cases  are  masked,  and 
may  be  developed  by  irritation  or  by  the  administration  of 
drugs  given  for  therapeutic  or  diagnostic  purposes.  One  must 
not  be  influenced  by  just  a  few  symptoms  which  are  present, 
nor  should  the  diagnosis  be  excluded  because  a  certain  num- 
ber of  symptoms  are  absent.  When  viewed  from  the  psychic 
sphere  alone,  the  mental  phenomena  of  undersecretion  of  the 
thyroid  or  pituitary  and  oversecretion  of  the  thyroid  or  pitui- 
tary may  occasionally  resemble  each  other,  yet  attention  to 
other  points  of  diagnosis  usually  aids  in  making  the  differential 
distinction  eventually  and  then,  after  all,  the  administration 
of  thyroid  and  placental  extract  eventually  gives  us  the  clue  we 
want.  In  a  large  proportion  of  cases  we  have  an  overactivity 
or  an  underactivity  of  thyroid  and  pituitary  posterior  and 
adrenal  medulla.  In  the  same  way  we  must  depend  upon 
long  observation,  upon  the  study  of  minute  points,  on  an 
observation  of  the  individual  in  the  interval  between  men- 
struation, and  the  effect  of  drugs,  and  local  therapeutic  meas- 
ures in  making  a  diagnosis  of  these  premenstrual  cases.  It  is 
well  to  remember  that  posterior  pituitary  plus  and  thyroid  mi- 
nus is  a  frequent  combination  and  that  high  blood  pressure  is 
then  a  symptom.  Many  of  the  symptoms  are  simply  due  to  over- 
stimulation by  the  ovarian  secretion  and  the  corpus  luteum, 
and  it  has  been  my  desire  to  attract  attention  to  cases  where 
the  annoyances  are  due  to  the  thyroid  gland  which,  hyper- 
secreting  or  not  at  other  times,  is  aroused  to  overactivity  by 
ovarian  and  corpus  luteum  stimulation.  And  right  here,  too, 
we  must  not  overlook  the  type  where  an  actual,  or  relative,, 
hypothyroidism  is  concerned  in  the  premenstrual  and  men- 
strual phase.  In  gynecology  we  have  been  suf¥ering  for  years 
with  the  idea  that  the  sex  organs,  through  reflex  channels. 


228  THE    ENDOCRINES 

have  dominated  a  woman's  physical  and  nervous  makeup. 
Lacerations  of  the  cervix  have  been  operated  on,  retroversion 
of  the  uterus  has  been  corrected,  prolapse  of  the  ovary  has 
attracted  great  attention,  and  various  anomalies  of  the  uterine 
lining  have  been  considered,  all  of  them,  by  reflex  channels, 
to  produce  headaches,  palpitation  of  the  heart,  nervousness, 
irritability,  indigestion,  and  mental  diseases.  I  have  no  ob- 
jection to  surgeons  doing  all  the  work  they  wish  on  the  inter- 
nal genitalia  for  mechanical  and  other  reasons,  but,  as  com- 
mon-sense physicians,  we  must  get  out  of  the  idea  that  by 
reflexes  these  lesions  play  their  role.  It  is  only  when  we  un- 
derstand the  makeup  of  woman,  the  relation  between  ovary 
and  thyroid,  pituitary,  adrenals,  etc.,  the  effect  of  rest,  the 
valuable  influence  of  the  correction  of  congestion;  it  is  only 
when  mental  and  psychic  stimuli  and  irritations  and  the  effect 
of  sexual  stimulation  and  deprivation  or  abnormal  coitus  are 
considered,  that  we  can  intelligently  understand  the  nervous 
affections  of  womankind  and  treat  them  intelligently. 

During  all  the  years  that  the  uterus  is  present,  acted  on  by 
the  ovaries,  reacting  on  the  ovaries,  related  directly  or  indirect- 
ly to  the  thyroid,  pituitary  and  adrenals,  the  uterus  is  an  organ 
of  importance  only  from  the  standpoint  of  propagation,  and  all 
the  nervous  annoyances  from  which  women  suffer  because  of 
the  fact  that  they  have  ovaries  and  uterus  are  the  price  which 
they  pay  for  possessing  an  organ  necessary  to  motherhood. 
After  motherhood  is  no  longer  to  be  considered,  or  after  a  stage 
when  motherhood  should  no  longer  be  considered,  the  uterus  is 
absolutely  of  no  value.  So  long  as  it  is  productive  of  no  annoy- 
ances, all  is  well.  When  that  uterus  is  the  seat  of  benign  or 
malignant  growths,  operation  is  generally  recognized  as  the 
only  treatment  in  the  malignant  cases,  and  as  the  advisable 
one  in  a  large  number  of  the  benign  type.  Then  comes  the 
cases  where  the  uterus,  because  of  excessive  bleedings,  or  be- 
cause it  is  totally  prolapsed,  produces  annoyances  which  inter- 
fere with  the  patient's  comfort  and  health,  and  in  innumerable 
cases  the  uterus  is  removed.  Now,  if  the  uterus  because  it  is 
present  makes  menstruation  possible,  whether  it  simply  takes 


CONSTITUTIONAL    DYSMENORRHEA  229 

part  in  this  process,  or,  by  some  relation  to  the  ovary  and  thy- 
roid and  pituitary  stimulates  this  process,  it  is  nevertheless 
certain  that  premenstrual  and  menstrual  annoyances  of  the 
type  which  I  have  described  are  markedly  diminished,  if  not 
entirely  removed,  when  menstruation  no  longer  recurs.  Any 
procedure,  whether  it  is  thorough  curettage  or  atmokausis,  or 
the  use  of  drugs  or  the  x-ray,  which  will  stop  menstruation, 
without  a  too  sudden  cessation  of  ovarian  function,  benefits 
these  patients.  If  none  of  these  methods  are  of  avail,  and  the 
patient's  steady  or  recurrent  annoyances  are  sufficient  to  make 
her  life  miserable,  and  if  we  feel,  as  I  do,  that  removing  the 
uterus  and  preserving  the  ovaries  but  not  the  corpora  lutea 
will  improve  and  cure  this  patient,  then  removal  of  the  uterus, 
especially  through  the  vagina,  is  a  most  legitimate  operation. 
Thyroid  affections,  occurring  so  much  more  frequently  in 
women  than  in  men,  especially  of  the  type  of  Basedow's  disease 
or  myxedema  of  typical  character,  teach  us  that  the  minor 
gradations  of  these  diseases  are  also  so  much  more  frequent  in 
women  than  in  men.  Hence,  "nervousness"  of  a  type  in  which 
the  thyroid  is  the  important  factor,  or  only  a  contributing  fac- 
tor, are  responsible  for  the  fact  that  nervous  conditions  are  so 
much  more  frequent  in  women  than  in  men.  Small  wonder, 
then,  that  a  goodly  portion  of  women  suft'er  from  annoyances 
in  which  the  thyroid  and  pituitary  plays  a  part,  preceding  or 
during  menstruation,  a  time  at  which  the  vast  majority  of 
women  realize  that  they  are  put  to  a  severe  mental  and  nervous 
strain.  I  have  attempted  an  explanation,  theoretic  to  be  sure, 
of  the  frequency  of  thyroid  affections  in  women.  I  fail  to  see 
how  logic  can  lead  us  to  any  other  conclusion  than  that  the  sus- 
ceptibility of  the  thyroid  to  disease  is-  in  a  great  measure  due  to 
the  fact  that  its  relation  to  other  glands  is  an  unstable  one,  and 
that  it  is  hypersensitive  to  annoyances  and  irritations  of  what- 
ever nature.  Now,  just  as  eclampsia,  even  if  we  haven't  found 
the  actual  chemical  element  or  elements  which  produce  the 
tissue  changes,  is  certainly  due  to  the  action  of  cells  of  the 
ovum,  acting  directly  and  through  their  effect  on  other  glands, 
especially  the  pituitary  posterior,  the  thyroid  and  the  para- 


230  THE    ENDOCRINES 

thyroids,  upon  the  blood  and  tissues  of  the  body,  so  the  ovary 
and  the  corpus  luteum,  directly  or  through  other  glands,  act  on 
the  thyroid,  and  renders  it  liable  to  overactivity,  underactivity, 
or  malsecretion.  When  one  considers  the  phenomena  which 
lead  to  menstruation,  it  is  impossible  to  avoid  the  conclusion 
that  the  uterus,  by  its  very  presence,  and  in  all  probability  by 
elements  secreted  by  its  glandular  structures,  bears  an  im- 
portant relation  to  the  ovary,  so  that  in  the  last  analysis  the 
thyroid  acts  on  the  uterus  directly  or  through  the  medium  of 
the  ovaries,  the  uterus  acts  on  the  thyroid  directly  or  through 
the  medium  of  the  ovaries  or  other  glands. 

Conditions  due  to  hypothyroidism  and  to  hypopituitarism 
are  not  so  difficult  to  combat.  It  is  the  hyperthyroid  and  hyper- 
pituitary  cases  which  cause  the  trouble. 

Ovarian  residue  helps  dysmenorrhea  due  to  corpus  luteum. 
Suprarenal  extract  helps  symptoms  of  a  constitutional  character 
due  to  hyperthyroidism.  Placental  extract  and  thyroid  extract 
and  ovarian  residue  and  pituitary  anterior  benefit  cases  when 
the  symptoms  are  due  to  hyperpituitarism  posterior. 

Local  treatment  and  general  medication  can  help  many 
of  these  patients,  even  though  the  annoyances  may  recur  at 
subsequent  periods.  I  have  watched  some  of  these  patients 
for  nearly  ten  years,  and  many  of  them  have  responded  re- 
peatedly to  periods  of  treatment. 

Viewed  from  the  standpoint  of  the  medical  man,  it  might 
be  said  that  these  are  nervous  patients  made  worse  at  the  men- 
strual periods.  The  neurologist  might  think  of  them  as  neuras- 
thenics, irritated  by  the  premenstrual  phase.  Others  might 
consider  them  as  masked  Basedow  cases,  subject  to  various 
degrees  of  exacerbation  at  regular  intervals.  My  recent  experi- 
ences show  the  posterior  pituitary  plus  to  play  a  part  of  the 
very  greatest  importance.  The  gynecologist  was  formerly  in- 
clined to  attribute  annoyances  to  reflexes  sent  out  from  dis- 
placed pelvic  organs  or  from  altered  structural  conditions. 

As  a  matter  of  fact,  it  really  means  that  the  premenstrual 
phase  furnishes  us  with  an  index  of  the  patient's  nervous  sensi- 
tiveness, or  shows  us  how  stable  is  the  function  of  the  thyroid, 


CONSTITUTIONAL    DYSMENORRHEA  231 

the  pituitary,  the  adrenals,  etc.,  or  how  sensitive  they  are  to 
variations  in  the  cycHc  function  of  the  ovaries,  corpus  luteum 
and  the  uterus. 

It  is  the  cases  suffering  from  menorrhagia,  phis  these 
cyclic  nerve  upsets,  that  furnish  the  most  marked  indication  for 
operative  interference. 

The  annoyances  which  occur  in  the  chmacterium  are  of 
various  forms.  The  nerve  phenomena  show  variations  from 
the  phlegmatic  type  to  the  excitable  type.  The  psychic  varia- 
tions run.  from  melancholic  and  psychasthenic  to  manic  forms. 
The  annoyances  are  clearly  the  result  of  changes  incident  to 
the  climacterium.  In  some  they  resemble  various  forms  of 
mental  diseases,  and  seem  ofttimes  to  have  nothing  to  do 
with  the  interglandular  upset,  but  we  know  now  that  they 
have.  It  is  of  course  necessary  to  recall  the  severe  forms 
which  are  coincident  wath  the  preclimacteric  or  climacteric 
phase  and  the  milder  or  severe  forms  which  develop  after  the 
alterations  of  that  period.  Some  women  go  through  this 
time  of  life  with  scarcely  a  ripple  to  mar  their  good  health, 
while  others  are  miserable  and  unhappy  for  months  or  years. 

There  are  women  who  are  in  this  so-called  change-of-life 
state  (if  that  be  used  to  signify  an  abnormal  relation  to  and 
between  the  secretions)  during  the  greater  part  of  their  life, 
or  for  certain  months  of  their  existence,  or  preceding  a  few 
or  many  or  all  of  their  menstrual  periods,  and  who  suffer  from 
the  same  variations,  in  the  way  of  annoyances,  as  the  class  just 
mentioned,  who  are  about  to  go  or  are  going  into  the  climac- 
terium. There  is  too  much  ovarian  stimulation  or  too  little 
ovarian  secretion;  there  is  too  much  thyroid  actually  or  rela- 
tively or  there  is  too  little  thyroid;  there  is  a  posterior  pitui- 
tary overactivity  or  underactivity  or  an  adrenal  over  or  under- 
activity, or  there  is  a  play  between  these  various  alterations. 
Posterior  pituitary  overactivity  is  at  this  period  productive  of 
the  largest  number  of  physical  and  psychic  annoyances. 


CHAPTER    XII 
INSTINCTS  AND  EMOTIONS 

We  seem  justified  in  believing  that  each  kind  of  instinctive 
behavior  is  always  attended  by  some  emotional  excitement, 
however  faint,  which  in  each  case  is  specific  or  peculiar  to  that 
kind  of  behavior.     (McDougall.) 

McDougall  defines  an  instinct  as  "an  inherited  or  innate 
psycho-physical  disposition  which  determines  its  possessor  to 
perceive  and  to  pay  attention  to  objects  of  a  certain  class,  to 
experience  an  emotional  excitement  of  a  particular  quality 
upon  perceiving  such  an  object  and  to  act  in  regard  to  it  in 
a  particular  manner  or  at  least  to  experience  an  impulse  to 
such  action." 

Doctor  and  Mrs.  Peckham  say:  "Under  the  term  in- 
stinct, we  place  all  complex  acts  which  are  performed  previous 
to  experience  and  in  a  similar  manner  by  all  members  of  the 
same  sex  and  race." 

Karl  Groos  goes  so  far  as  to  say  that  "The  Idea  of  con- 
sciousness must  be  rigidly  excluded  from  any  definition  of 
instinct  which  is  to  be  of  practical  utility." 

Every  instinctive  process  has  the  three  aspects  of  all  men- 
tal process,  the  cognitive,  the  affective  and  the  conative. 

The  innate,  psycho-physical  disposition  may  be  regarded 
as  consisting  of  an  afferent,  a  central  and  a  motor  or  efferent 
part. 

"From  the  afferent  part  (nerve  elements  receiving  elab- 
orating impulses  on  sense  organs),  the  excitement  spreads  over 
to  the  central  part  which  determines  the  distribution  of  the 
nervous  impulses,  some  of  which  descend  to  modify  the  work- 
ing of  the  visceral  organs  (the  heart,  lungs,  blood-vessels, 
glands,  etc.).  Others  go  to  the  central  nervous  system  and 
extend  to  the  efferent  or  motor  part  and  influence  the  muscles 
which  produce  the  instinctive  action."     (McDougall.) 

While  the  afferent  and  efferent  parts  may  be  modified,  the 
emotional  excitement  with  the  accompanying  nervous  activities 

232 


INSTINCTS  AND  EMOTIONS  233 

of  the  central  part  is  the  only  portion  of  the  total  instinctive 
process  that  retains  its  specific  character  and  remains  common 
to  all  individuals  and  all  situations  in  which  the  instinct  is 
excited.  The  afferent  element  has  inlets  through  any  or  all  of 
the  senses.  And  the  same  emotion  may  be  excited  through  any 
of  them. 

Each  sense  impression  may  be  presented  again  or  repro- 
duced in  idea,  and  may  therefore  as  a  representation  induce 
the  same  emotional  excitement  as  was  caused  by  the  original 
impression. 

Even  delicate  resemblances  to  the  original  impression  or 
to  its  representation  may  have  the  same  eifect. 

The  Instinct  of  Flight  and  the  Emotion  of  Fear. 

Terror  is  the  most  intense  degree  of  this  emotion. 

Instinctive  flight  is  followed  by  equally  instinctive  con- 
cealment. 

Fear  is  the  great  inhibitor  of  action,  both  present  and 
future.  Once  roused  it  haunts  the  mind,  comes  back  alike  in 
dreams  and  waking  life,  bringing  with  it  vivid  memories  of 
the  terrifying  impression. 

Fear  prompts  to  bodily  retreat  and  tends  to  inhibit  all 
other  impulses  than  its  ov/n. 

In  certain  mental  diseases  there  is  an  abnormal  excitabil- 
ity of  this  instinct.  The  patient  is  perpetually  in  fear.  Shrink- 
ing in  terror  from  the  most  harmless  animal  or  at  the  least 
unusual  sound  and  surrounds  himself  with  safeguards  to  pre- 
vent Impossible  dangers.     (McDougall.) 

The  Instinct  of  Repulsion  and  the  Emotion  of  Disgust. 

The  impulse  of  this  instinct  is,  like  that  of  fear,  one  of 
aversion,  and  these  two  instincts  together  probably  account 
for  all  aversions  except  those  acquired  under  the  influence  of 
pain. 

While  the  impulse  of  fear  prompts  to  bodily  retreat,  the 
impulse  of  repulsion  prompts  to  removal  or  rejection.  The 
first  impulse  of  repulsion  is  evidenced  by  babies.  The  mouth 
rejects  because  of  odor  or  taste.     The  other  impulse  of  re- 


234  THE    ENDOCRINES 

pulsion  is  excited  by  the  contact  of  slimy  or  slippery  sub- 
stances with  the  skin, — hence  shrinking  and  a  creepy  shudder. 

The  Instinct  of  Curiosity  and  the  Emotion  of  Wonder. 
It  is  not  always  easy  to  distinguish  in  general  terms  be- 
tween the  excitants  of  curiosity  and  those  of  fear,  for  one  of 
the  most  general  excitants  of  fear  is  whatever  is  strange  or 
unfamiliar.  This  instinct  exhibits  great  individual  differences ; 
the  impulse  grows  weaker  for  lack  of  use  in  those  in  whom  it 
is  innately  weak ;  it  becomes  stronger  through  exercise  in  those 
in  whom  it  is  innately  strong.  In  the  latter  type  it  may  become 
the  main  source  of  energy  and  effort.  It  is  one  of  the  principal 
roots  of  science  and  religion. 

The  Instinct  of  Pugnacity  and  the  Emotion  of  Anger. 
"This  instinct  is  apparently  lacking  in  the  constitution  of 
the  female  of  some  species.  In  the  animals  the  most  furious 
excitant  of  this  instinct  is  produced  by  hunger ;  and  in  the  male 
of  many  species  by  any  interference  with  the  satisfaction  of 
the  sexual  impulse.  Such  interference  is  the  most  frequent 
occasion  of  its  excitement.  The  obstruction  of  every  other 
instinctive  impulse  may  in  its  turn  become  the  occasion  of 
anger.  The  man  devoid  of  the  pugnacious  instinct  is  not  only 
incapable  of  anger  but  lacks  this  great  source  of  reserve  energy 
called  into  play  by  difficulties.  It  is  the  opposite  of  fear  which 
tends  to  inhibit  all  other  impulses  than  its  own."    (McDougall.) 

The  Instinct  of  Self-Assertion  or  Self-Display  and 
THE  Emotion  of  Elation  or  Positive  Self-Feel- 
ing. 
"Many  children  clearly  exhibit  the  instinct  of  self-display. 
The  instinct  may  find  expression  in  boasting  and  swaggering, 
vanity,  etc.     This  instinct  is  excited  by  the  presence  of  specta- 
tors to  whom  one  feels  in  any  way  superior.    In  certain  mental 
diseases,  especially  in  the  early  stages  of  general  paresis,  the 
exaggeration  of  this  emotion  and  its  impulse  of  display  is  the 
leading  symptom.     There  is  a  perpetual  state  of  elated  self- 
feeling  and  the  behavior  corresponds  to  this  emotional  state. 
The  individual  boasts  of  his  strength,  his  immense  wealth,  his 


INSTINCTS  AND  EMOTIONS  235 

good  looks,  his  luck,  his  family,  when  perhaps  there  is  not 
the  least  foundation  for  these  boastings." 

The  Instinct  of  Self-Abasement  or  Subjection  and  the 
Emotion  of  Subjection  or  Negative  Self-Feel- 
ing. 
The  instinct  of  this  impulse  exhibits  itself  in  a  slinking, 
crestfallen  behavior,  a  general  diminution  of  muscular  tone, 
slow  restricted  movements,  a  hanging  down  of  the  head,  and 
sidelong  glances.  In  children  the  expression  of  this  emotion 
is  often  mistaken  for  that  of  fear.  In  many  cases  of  mental 
disorder  we  observe  the  exaggerated  influence  of  this  instinct. 
The  patient  shrinks  from  the  observation  of  his  fellows,  thinks 
himself  a  most  wretched,  sinful  creature,  and  in  many  cases 
develops  delusions  of  having  performed  unworthy  or  even 
criminal  actions.  Many  such  patients  declare  they  are  guilty 
of  the  unpardonable  sin,  although  they  do  not  attach  any 
definite  meaning  to  the  phrase.  The  patient's  intellect  en- 
deavors to  justify  the  persistent  emotional  state  which  has  no 
adequate  cause  in  his  relations  to  his  fellow  men.  (McDougall.) 

The  Parental  Instinct  and  the  Tender  Emotion. 

The  human  species  is  dependent  on  this  emotion  for  its 
continued  existence  and  welfare.  This  is  the  most  powerful 
of  the  instincts,  and  is  accompanied  by  a  strong  and  definite 
emotion.  This  instinct  and  its  emotion  are  v/eaker  in  man 
that  in  woman, — in  some  men  altogether  lacking.  The  philos- 
ophers as  a  class  are  men  among  whom  this  defect  of  native 
endowment  is  relatively  common.  Its  impulse  is  primarily 
to  afford  physical  protection  to  the  child,  especially  by  throw- 
ing the  arms  about  it.  The  impulse  being  essentially  protec- 
tive, its  obstruction  promotes  anger,  perhaps  more  markedly 
than  the  obstruction  of  any  other. 

The  intimate  alliance  between  tender  emotion  and  anger 
is  of  great  importance  for  the  social  life  of  man.  In  those 
women  in  whom  the  instinct  is  strong  it  is  apt  to  be  excited 
owing  to  the  subtle  working  by  any  and  every  object  that  is 
small  and  delicate, — as  a  small  cup,  or  chair,  or  book,  etc. 


236  the  endocrines 

The  Sexual  Instinct  or  the  Instinct  of  Reproduction. 
This  instinct  more  than  any  other  lends  the  immense 
energy  of  its  impulse  to  the  sentiments  and  complex  impulses 
into  which  it  enters  while  its  specific  character  remains  sub- 
merged and  unconscious. 

Sexual  Jealousy  and  Female  Coyness. 

The  specially  intimate  innate  connection  between  the  in- 
stinct of  reproduction  and  the  instinct  of  pugnacity  account 
for  the  fact  that  the  anger  of  the  male  is  so  readily  aroused 
by  any  threat  of  opposition  to  the  operation  of  the  sexual 
impulse.  The  coyness  of  the  female  is  due  to  the  fact  that  the 
instinct  of  reproduction  has  intimate  innate  relations  to  the 
instincts  of  self-display  and  self-abasement.  (Lack  of  adrenal 
cortex  and  cells  of  Gley. ) 

The  Gregarious  Instinct  plays  a  great  part  in  mould- 
ing societary  forms.  It  implies  an  uneasiness  in  isolation  and 
satisfaction  in  being  one  of  a  herd.  This  instinct  is  commonly 
strongly  confirmed  by  habit.  The  morbid  intense  working  of 
this  instinct  is  known  as  agoraphobia.  The  patient  will  not 
remain  alone ;  will  not  cross  a  wide  empty  space ;  seeks  always 
to  be  surrounded  by  other  human  beings.  Professor  James 
said  of  the  normal  man,  "To  be  alone  is  one  of  the  greatest 
of  evils  for  him."  Solitary  confinement  is  by  many  regarded 
as  a  mode  of  torture. 
The  Instinct  of  Acquisition. 

The  instinct  or  the  impulse  of  collecting  and  hoarding, 
when  habitually  exaggerated,  leads  to  miserliness  and  klep- 
tomania. This  instinct  ripens  naturally  and  comes  into  play 
independently  of  all  training. 

The  Instinct  of  Construction  :  This  instinct  is  evi- 
denced in  the  playful  activities  of  children;  the  simple  desire 
to  make  something  rooted  in  this  instinct  is  probably  the  con- 
tributing motive  to  all  human  construction  from  a  mud  pie  to 
a  metaphysical  system  or  a  code  of  laws. 

The  Three  Most  Important  of  the  So-Called 
Pseudo-Instincts  Are  Suggestion,  Imitation,  and  Sym- 


INSTINCTS  AND  EMOTIONS  237 

PATHY.  Professor  James  has  said  "sympathy  is  an  emotion." 
The  sympathetic  induction  of  emotion  is  displayed  in  the 
simplest  and  most  unmistakable  fashion  by  all  gregarious  ani- 
mals, as  in  the  spread  of  fear  and  its  flight  impulse  among  the 
members  of  a  flock  or  herd. 

Laughter  is  notoriously  infectious  all  through  life,  and 
this  affords  a  most  familiar  example  of  a  sympathetic  induc- 
tion of  an  affective  state.  Sympathetic  sensibility  leads  many 
people  to  avoid  all  contact  with  distressful  persons,  books,  or 
scenes,  and  to  seek  the  company  of  the  careless  and  gay. 
(McDougall.) 
Suggestion  and  Suggestibility. 

Suggestion  is  the  process  of  communication  resulting  in 
the  acceptance  with  conviction  of  a  communicated  proposition 
in  the  absence  of  logically  adequate  grounds  for  its  acceptance. 
The  measure  of  suggestibility  is  the  readiness  with  which  prop- 
ositions are  accepted.  The  conflict  between  the  two  impulses 
of  submission  on  the  one  hand  and  of  self-assertion  on  the 
other  produces  the  complex  emotional  disturbance  known  as 
bashfulness.  In  so  far  as  the  impulse  of  submission  predomi- 
nates, we  are  suggestible  toward  the  person  whose  presence 
evokes  it.    Children  are  inevitably  suggestible. 

Contra-Suggestion  :  This  denotes  the  mode  of  action 
of  one  individual  on  another  which  results  in  the  second  ac- 
cepting in  the  absence  of  adequate  logical  grounds  the  con- 
trary of  a  proposition  asserted  or  implied  by  the  agent.  There 
are  persons  with  whom  this  result  is  very  liable  to  be  produced 
by  any  attempt  to  exert  suggestive  influence,  or  even  by  the 
most  ordinary  and  casual  utterance.  Some  children  display 
this  contra-suggestibility  very  strongly  for  a  period,  and  after- 
ward return  to  a  normal  degree  of  suggestibility.  But  in  some 
persons  it  becomes  habitual  or  chronic;  they  take  a  pride  in 
doing  and  saying  nothing  like  other  people,  in  dressing  and 
eating  differently,  in  defying  all  the  minor  social  conventions. 
Contra-suggestion  seems  to  be  determined  by  the  undue  domi- 
nance of  the  impulse  of  self-assertion  over  that  of  submission^ 
owing  to  the  formation  of  some  rudimentary  sentiment  of  dis- 


238 


THE    ENDOCRINES 


like  for  personal  influence,  resulting  from  the  unwise  exercise 
of  it. 

From  these  seven  instincts,  together  with  feelings  of  pleas- 
ure or  pain  and  feelings  of  excitement  or  depression,  are  com- 
bined practically  all  the  affective  states  that  are  popularly  recog- 
nized as  emotions.     (McDougall.) 

The  Instincts,  the  Emotions,  and  the  Endocrines 

Just  as  the  newly-born  inherits  facial  resemblance  and 
innumerable  physical  and  other  characteristics  and  traits, 
so  too  is  it  born  with  instincts  which,  though  common  to 
all,  are  certainly  inherited  in  varying  degrees  of  intensity 
and  combination  along  Mendelian  lines.  "Nature,"  the 
endocrine  glands,  the  type  of  life,  sanitary  conditions,  food, 
intercurrent  diseases,  etc.,  influence  and  may  determine 
the  type  of  physical  and  mental  growth.  Hunger,  in- 
ternal processes,  and  environment  furnish  the  first  stimuli 
which  act  on  the  instincts  and  result  in  emotions.  Training, 
instruction,  education,  changes  of  a  physiological  and  path- 
ological nature  enter  into  play  and  the  result  is  the  developing 
boy  or  girl  who  continues  through  life  still  acted  on  and  af- 
fected by  the  same,  or  by  altered  types  of  internal  and  external 
influence.  What  is  in  a  person  is  shown  by  his  behavior.  The 
behavior  of  animals,  of  the  newly-born  and  of  the  young  has 
informed  us  about  instincts,  and  their  expression  in  humans 
leads  to  emotions  and  subsequently  plays  an  important  role  in 
disposition  and  character.  We  inherit  our  instincts,  our  emo-' 
tions,  and  our  endocrines. 

People  are  well  and  healthy,  or  ill  and  sick.  They  are 
normal  or  neuropathic.  They  are  normal  or  psychopathic. 
People  may  be  cheerful  or  morose  "by  nature,"  as  we  call  it; 
energetic  or  lazy ;  yielding  or  stubborn ;  full  of  ambition  or  in- 
different; sweet  or  sour;  they  may  have  been  one  and  have 
become  the  other.  Some  people  are  courageous,  others  are 
cowardly;  some  have  been  one  or  the  other,  and  events  and 
accidents  may  modify  these  qualities  temporarily  or  perma- 
nently.    A  well  person  may  become  ill,  an  apparently  normal 


INSTINCTS  AND  EMOTIONS  239 

person  may  become  neuropathic  or  psychopathic.  An  individ- 
ual may  have  been  practically  well  always  or  more  or  less  ill 
always.    But  endocrine  action  is  the  dominating  factor. 

Practically  every  adult  who  dies  would  show  at  autopsy 
an  evidence  somewhere  of  a  previous  tuberculous  lesion.  The 
vast  majority  never  develop  real  recognized  tuberculosis  in 
any  form;  others  develop  it  in  a  recognized  form  in  glands, 
bones,  joints,  kidneys,  lungs,  etc. 

If  we  understand  the  body  and  its  ills,  we  seek  to  correct 
them  medically  or  surgically. 

Do  we  understand  and  study  the  mental  and  psychic  make- 
up and  mental  reactions  sufficiently  to  realize  the  numerous 
gradations  between  the  normal  mind  and  psyche  and  the  gross 
abnormalities  of  either?  Language  shows  that  we  should, 
We  say  "peculiar,"  "temperamental,"  "odd  character,"  "nerv- 
ous type,"  "hysterical,"  "rolling-stone,"  "weak  character," 
"neurasthenic,"  "eccentric,"  without  realizing  sufficiently  that, 
while  we  are  referring  to  characteristics  and  traits,  we  are 
concerned  with  psychic  conditions  differing  from  the  average 
or  the  normal.  In  fact,  adjectives  prove  in  language  the 
purpose  or  intention  of  defining  differences  of  any  sort.  En- 
docrine action  is  the  dominating  factor  also. 

The  average  mind  recognizes  the  distinction  between  ex- 
tremes; but  unless  trained  or  inherently  analytical,  it  grasps 
less  readily  the  intervening  gradations.  The  medical  mind 
is  taught  the  symptoms  of  disease  along  the  same  lines,  yet 
observation  proves  that  there  are  gradations  or  variations  in 
the  intensity  of  practically  all  the  body  ills.  The  medical  man 
knew  a  typical  Basedow's  disease  when  he  saw  it,  but  it  has 
taken  fifteen  or  more  years  to  absorb  the  knowledge  that  there 
are  variations  in  intensity  down  to  what  are  now  recognized 
as  the  milder  forms  of  hyperthyroidism.  The  physician  was 
taught  to  diagnose  a  well-defined  case  of  myxedema;  he  now 
recognizes  even  a  mild  or  occasional  hypothyroidism.  Every- 
one knows  that  from  the  extreme  pulmonary  tuberculosis,  in- 
curable and  fatal,  there  are  gradations  down  to  the  mild,  in- 
cipient form  which  may  often  be  recognized  only  by  the  most 


240  THE    ENDOCRINES 

expert,  and  that  too  only  with  the  aid  of  the  most  modern 
technical  apparatus. 

Everyone  knows  that  epidemics  of  influenza  may  be  not 
only  of  varying  degrees  of  severity,  but  that  they  produce 
symptoms  varying  from  the  severest  forms  of  pneumonia  and 
psychoses  to  simple  slight  indisposition.  And  so  throughout 
the  whole  realm  of  medicine,  our  knowledge  is  brought  to  us 
by  the  study  of  the  extreme  types,  because  from  them  we  re- 
ceive the  imprints  which  focus  our  attention  on  the  various 
major  and  also  minor  details,  and  it  is  only  by  the  recall  of 
many  seeming  details  that  we  can  diagnose  the  incipient  stages 
of  many  of  the  physical,  mental,  and  psychic  ills. 

Therefore,  to  secure  a  knowledge  concerning  the  en- 
docrines  and  their  importance,  and  to  be  able  to  recognize  their 
gradations,  pointing  to  their  over-  and  under-activity,  we  must 
study  some  of  the  endocrine  diseases  in  their  extreme  form, 
retaining  a  clear  picture  obtained  not  only  through  the  eye 
but  through  the  recognition  of  all  the  smaller  manifestations. 
It  is  not  sufficient  to  consider  Basedow's  disease,  for  instance, 
as  simply  exophthalmos,  goiter,  tachycardia,  and  tremor;  one 
must  know  the  innumerable  changes  in  almost  every  function 
of  the  body  associated  with  this  disease,  the  study  of  which 
has  taught  us  that  most  valuable  pathology  which  the  dis- 
secting table  or  the  pathological  laboratory  is  unable  to  sup- 
ply. On  the  other  hand,  the  pathologist,  both  in  his  gross 
pathology  and  in  his  microscopic  work,  has  furnished  us  and 
will  still  further  furnish  us  with  a  knowledge  as  to  which  of 
the  glands,  what  parts  of  the  glands,  and  what  character  of 
changes  are  the  responsible  seats  or  factors  for  those  diseases 
and  abnormalities  and  symptoms  with  which  we  have  to  deal. 

Those  most  worthy  and  insufficiently  recognized  investi- 
gators who  have  experimented  on  animals  have  contributed  a 
huge  and  most  valuable  quota  to  our  knowledge  of  the  physio- 
logical action  of  the  endocrines  and  the  specific  effects  Vv^hich 
the  endocrines  produce  on  various  organs,  structures,  and 
functions  of  the  body.  The  alienists  and  the  psychiatrists  have 
given  us  a  knowledge  of  the  manifestations  and  symptoms  of 


INSTINCTS  AND   EMOTIONS  241 

mental  disease  and  are  continually  finding  and  unraveling  the 
mysterious  and  wonderful  functions  of  brain  areas,  centers, 
and  structure  in  their  relation  to  mental  and  psychic  processes. 

The  neurologists,  let  us  forget  the  Freudians,  by  delving 
into  the  hidden  and  often  forgotten  accidents  and  into  the 
resulting  effects  and  impressions  of  life  and  experience,  ex- 
pose the  tremendous  inuflence,  not  only  of  the  conscious  but 
of  the  subconscious. 

Psychologists,  by  their  study  of  the  primitive  and  inherent 
instincts  and  resulting  emotions,  have  exposed  to  us  the  knowl- 
edge that  different  beings  react  to  different  stimuli  according 
to  laws  often  as  fixed  and  as  specific  as  the  reaction  of  chem- 
istry and  the  laws  of  physics.  But  here  we  do  not  grant  readily 
enough  the  association  of  endocrine  activity  zvith  the  emo- 
tions and  the  instincts,  the  most  important  point  of  all. 

The  resemblance  of  a  new-born  infant  to  either  of  its 
parents  or  grandparents  is  due  to  the  fact  that  a  like  endocrine 
action  has  taken  place  along  the  phase  of  body-development. 
If  a  child  resembles  either  of  its  parents  or  its  grandparents 
in  instincts,  emotions,  mind,  and  psyche,  it  is  because  a  like 
endocrine  action  has  taken  place  in  the  two.  Twins  born  in 
the  same  sac  Jiave  developed  from  the  same  fecundated  ovum 
which,  after  its  first  cell  division,  allowed  each  of  these  two 
halves  to  develop  as  an  independent  ovum.  Hence  such  twins 
are  alike  in  sex,  in  appearance,  in  characteristics,  in  nature, 
etc.  Twins  which  have  developed  from  two  different  ova  are 
in  two  separate  sacs  and  may  be,  and  usually  are,  as  unlike  as 
any  two  children  of  the  same  parents  born  at  different  times. 
When  people  totally  unrelated  resemble  each  other,  it  shows 
that  they  are  the  products  of  like  endocrine  action  and  rela- 
tion. If  they  resemble  each  other  in  disposition,  traits,  and 
character  it  shows  that  they  possess  corresponding  and  similar 
endocrine  activity.  When  people  are  peculiar  and  abnormal 
any  who  have  the  same  deviations  from  the  normal  sug- 
gest that  like  or  similar  endocrine  activity  has  taken  place  in 
either.  When  individuals  have  a  psychosis  of  any  definite 
distinct  type   and  their  symptoms  are   alike   it   suggests  the 


242  THE    ENDOCRINES 

same  disturbance  of  endocrine  action  and  interplay  in  two 
totally  unrelated  individuals  endowed  with  like  instincts  and 
emotions.  When  individuals  having  the  same  type  of  psychosis 
react  in  the  same  way  in  their  attitude  and  show  more  or  less 
the  same  psychic  elements  of  reaction  one  is  justified  in  re- 
garding their  endocrine  interplay  as  approximately  the  same. 
Therefore  resemblances  in  body,  form,  or  in  features  or  in 
ability  or  in  character  or  in  mind  or  psyche  are  important  to 
the  physician  in  attracting  his  attention  to  the  fact  that  many 
people  who  resemble  each  other  or  look  alike  may  be  and  often 
are  alike  in  other  respects. 

It  is  only  by  a  bringing  together  of  the  most  essential 
and  varied  points  brought  to  our  knowledge  by  the  scientists 
and  investigators  in  the  fields  above  mentioned  that  a  physi- 
cian can  obtain  a  sufficiently  comprehensive  and  amalgamated 
knowledge  of  the  human  being  as  a  whole. 

Then  comes  the  question  of  what  to  do  and  how  to  do 
it  in  the  best  possible  manner.  So  far  as  the  endocrines  and 
therapy  by  endocrines  is  concerned,  exact  knowledge  as  to  in- 
dications for  administration  and  as  to  the  value  of  the  different 
gland  extracts  can  be  obtained  only  by  their  use  by  the  human 
being,  however  much  experimentation  on  animals  may  have 
taught  us.  Therefore  to  equip  oneself  adequately  for  endocrine 
therapy,  these  gland  extracts  must  be  tried,  as  they  are  being 
tried  and  will  be  tried  in  a  continually  increasing  field  of  en- 
deavor; each  specialist  of  necessity  studying  gland  psysiology, 
pathology,  and  therapy  in  its  more  particular  relation  to  his 
field  of  work.  Let  me  say  here  that  for  years  90  per  cent,  of 
all  my  medication  has  consisted  of  endocrine  extracts. 

To  initiate  endocrine  therapy  properly  in  gynecology, 
one  must  attempt  the  study  of  the  relation  of  the  endocrines 
to  the  physiological  functions  of  woman  in  the  varying  periods 
of  her  life;  and  must  continually  study  the  possible  relation 
of  deviations  of  glandular  activity  to  many  of  the  pathological, 
physical,  mental,  and  psychic  manifestations  with  which  he 
has  to  deal.  And  this  holds  true  for  children  as  well  as  adults. 
And  right  here,  so  far  as  our  children  are  concerned,  is  the 


INSTINCTS  AND   EMOTIONS  243 

most  important  field  for  therapy.  Therefore  many  of  the 
associations  between  glandular  abnormality  and  pathological 
states  are  at  first  only  suggestive  as  to  cause  and  effect.  But, 
if  these  seeming  coincidences  occur  sufficiently  often  in  one's 
practice,  the  suggestive  becomes  the  probable;  and  the  more 
frequently  does  it  repeat  itself,  the  more  nearly  does  it  approach 
a  fact. 

A  comprehensive  study  of  the  endocrines  in  general  is 
an  ever  increasingly  huge  task.  One  may  take  up  this  study 
for  the  sake  of  individual  pleasure  and  find  in  it  a  worthy 
reward ;  but  most  of  us  have  entered  into  the  study  of  this  all 
absorbing  question  because  it  seemed  to  furnish  us  not  only 
with  an  explanation  for  many  phases  which  seemed  puzzling, 
but  because  it  offered  a  prospect  of  supplying  the  means  by 
which  we  might  benefit  our  patients.  A  man  may  be  a  very 
good  physician  and  yet  have  forgotten  ninety  per  cent,  of  all 
the  anatomy  studied  so  laboriously  and  with  so  much  drudgery 
in  our  medical  schools;  a  man  may  read  the  entire  literature 
of  the  endocrines  and  forget  ninety  per  cent,  and  still  retain 
the  essential  points  and  factors  which  particularly  interest  him, 
especially  from  the  practical  side.  But  he  can  gain  a  proper 
understanding  of  the  problem  only  by  observing  therapeutic 
results. 

When  I  was  a  student  of  medicine,  Professor  Allen  Starr 
showed  a  case  of  myxedema,  typical  in  appearance,  one  never 
to  be  forgotten.  The  patient  was  a  school  teacher  who  had 
left  England  because  her  memory  had  failed  her;  her  mental 
faculties  had  changed  so  that  her  vocation  could  not  be  pur- 
sued. I  remember  with  what  glee  and  confidence  he  told  us 
that  the  patient  could  be  cured,  now  that  we  w-ere  no  longer 
feeding  with  the  gland  itself  but  were  giving  a  glycerin  ex- 
tract ;  and  not  long  thereafter  thyroid  extract  w^as  used  thera- 
peutically and  I  have  used  it  ever  since. 

I  remember  a  clinic  of  Professor  Delafield's,  w^hen  he 
showed  a  big,  broad-shouldered,  powerfully  built  stoker  com- 
plaining of  palpitation  of  the  heart.  After  a  thorough  exami- 
nation, he  said  in  words  that  I  have  never  forgotten :    "This  is 


244  THE    ENDOCRINES 

a  case  of  exophthalmic  goiter  without  exophthalmos  and  with- 
out goiter,"  The  meaning  of  that  diagnosis  has  influenced  me 
ever  since,  and  early  in  my  gynecological  practice  I  studied  my 
cases  and  published  a  large  series  under  the  title,  "Associated 
Nervous  Conditions  in  Gynecology,"  the  main  purpose  being 
to  show  that  hyperthyroidism  was  a  most  frequent  cause  of 
these  nervous  conditions,  and  that  it  existed  without  the  so- 
called  pathognomonic  signs  of  Basedow's  disease. 

Nearly  twenty  years  ago  Knauer  made  those  interesting 
transplantations  of  ovaries  m  animals  which  proved  that  the 
ovaries  exerted  their  trophic  action  on  the  genitalia  by  virtue 
of  a  secretion  and  not  by  a  reflex  promoted  by  ripening  of  the 
follicles.  Since  that  time  I  have  been  using  ovarian  secretion 
(corpus  luteum  much  less  frequently  than  the  whole  gland), 
and  later  the  secretion  of  the  interstitial  substance,  both  by 
mouth  and  by  hypodermic;  and  with  every  year  the  results 
in  an  ever  widening  series  of  appropriate  cases  are  more  than 
gratifying. 

Several  years  ago  came  the  introduction  of  pituitrin  into 
obstetrics,  calling  attention  to  the  relation  between  a  gland 
seated  in  the  brain  and  an  organ  so  distant  and  so  special  in 
its  activities  and  functions  as  the  uterus.  Cushing's  work  de- 
serves the  highest  praise,  aside  from  his  surgical  accomplish- 
ments, because  his  reports  of  cases  contain  references  to  the 
effects  of  the  pituitary  diseases  on  menstruation ;  and  the 
frequent  references  to  associated  thyroid  anomalies  and  adrenal 
anomalies  have  done  so  much  to  focus  our  attention  on  what 
are  now  called  pluriglandular  or  polyglandular  involvements; 
that  is,  the  fact  that  a  severe  change  in  one  important  gland 
influences  or  is  associated  with  changes  in  associated  glands. 
But  an  added  feature  is  the  photographs  of  patients  in  their 
earlier  periods  before  a  pituitary  disease  began  to  be  mani- 
fested ;  and  the  photographs  of  the  same  patients  at  the  time 
of  operation.  Could  anything  be  more  instructive  than  the 
study  of  the  changes  in  facial  contour,  growth  of  the  facial 
bones,  changes  in  the  jaw,  in  the  teeth,  in  the  hands,  etc.  ?  As- 


INSTINCTS  AND  EMOTIONS  245 

sociated  therewith  are  the  changes  in  metaboHsm  and  in  the 
mental  attitude,  the  psychic  sphere. 

As  a  result  of  such  study  one  is  able  to  note  by  observa- 
tion of  the  face  alone,  the  existence  of  a  well-defined  endocrine 
over-  or  under-activity  or  alteration.  One  may  see  and  thus 
recognize  the  slighter  changes  produced  by  the  influence  of  like 
secretory  activity.  No  one  finds  any  difficulty  in  recognizing 
a  well-defined  case  of  Basedow's  disease  or  acromegaly  or 
myxedema  at  sight.  Between  these  extreme  resemblances  and 
types  and  the  so-called  minor  or  latent  forms  there  are  grada- 
tions of  varying  degrees  which  may  still  be  recognized  by  the 
eye.  This  recognition  directs  our  attention  to  over-  or  under- 
activity of  a  gland  or  glands  through  the  suggestive  resem- 
blance. Add  to  this  the  knowledge  we  have  gained  concern- 
ing the  influence  of  the  endocrines  on  texture  of  the  skin,  dis- 
tribution of  hair,  dryness  or  moisture  of  the  skin,  character 
and  development  of  the  teeth,  pigmentation,  feeling  of  physical 
and  mental  languor,  asthenia,  the  meaning  of  blood  pressure, 
sugar  tolerance,  rate  of  the  pulse,  etc.,  and  it  is  easy  to  recog- 
nize how  hugely  our  diagnostic  acumen  has  been  furthered. 

In  diagnosis  it  is  no  longer  a  question  of  bimanual  exami- 
nation, of  listening  to  the  lungs,  to  the  heart,  testing  the  blood- 
pressure,  examining  the  urine,  examining  the  blood,  etc.  It  is 
a  matter  of  observation  and  also  of  tests  to  determine  what  the 
endocrines  have  been  doing  to  a  patient  before  she  comes  to 
us ;  and  then  it  is  for  us  to  determine  what  the  endocrines  are 
doing  at  the  time  the  patient  consults  us ;  and  if  the  patient 
sufifers  from  too  little  of  a  secretion  necessary^  to  her  well- 
being,  what  is  easier  than  to  administer  it?  And  if  she  be 
suffering  because  of  an  excess  of  any  one  or  more  secretions, 
what  better  outlook  has  medicine  than  to  search  for  and  find, 
if  possible,  the  counteracting  remedies  ? 

Now,  when  patients  come  to  the  g}mecologist,  not  all  are 
to  be  helped  by  surgical  means  or  by  surgical  means  only.  A 
goodly  proportion  of  them  come  because  of  disturbances  asso- 
ciated with  menstruation.  Here  we  have  the  various  degrees 
of  amenorrhea,  dysmenorrhea,  menorrhagia,  and  metrorrhagia. 


246  THE    ENDOCRINES 

Not  all  the  menorrhagias  and  metrorrhagias  are  due  to  polyps 
or  fibroids  of  tlje  uterus.  A  very  large  number  of  fiboids  have 
no  menorrhagia  or  metrorrhagia  as  a  symptom.  If  we  can  hold 
out  hope  of  a  cure  for  these  patients  with  medication,  why 
should  we  dilate  or  do  a  plastic  on  the  cervix,  or  curette  ?  How 
is  a  patient,  suffering  from  repeated  miscarriage,  to  be  benefited 
by  the  removal  of  the  uterine  lining  when  examination  shows 
it  to  be  smooth  and  normal? 

Then  we  have  the  annoyances  which  precede  each  men- 
struation, of  which  patients  complain  so  frequently;  we  have 
the  annoyances  associated  with  the  climacterium  and  meno- 
pause. Not  always  are  climacterium  and  menopause  coinci- 
dent. Many  patients  believe  that  long  periods  of  nervous  up- 
set, headaches,  etc.,  must  be  due  to  some  anomaly  in  the  genital 
tract.  This  notion  seems  to  be  general  among  the  laity,  and 
it  is  only  too  true  that  gynecology  of  the  past  few  decades  has 
assisted  in  fostering  it.  Hence  the  mania  for  doing  a  trachelor- 
rhaphy to  correct  all  sorts  of  symptoms  supposedly  reflex  and 
supposedly  due  to  this,  in  my  opinion,  unimportant  cervical 
condition.  Slight  deviations  of  the  uterus  have  been  corrected 
in  thousands  of  cases  for  the  same  purpose. 

It  was  because  of  my  disbelief  in  this  etiology  and  my 
disinclination  to  advise  surgical  procedures  against  my  belief 
that  my  attention  was  directed  still  more  definitely  to  aberra- 
tions of  the  endocrine  system  as  scientific  and  logical  explana- 
tions for  those  varying  neuroses  and  psychoses  erroneously 
called  "hysteria"  and  "neurasthenia."  The  extent  to  which 
hyperthyroidism  and  hypothyroidism,  for  instance,  are  now 
made  as  diagnoses  for  many  of  the  annoying  symptoms  for- 
merly called,  and  indiscriminately  so,  "hysteria"  and  "neuras- 
thenia," is  only  one  of  the  many  proofs  of  the  correctness  of 
this  belief. 

Endocrine  abnormality  may  focus  its  effect  on  a  definite 
point  or  function.  An  affection  of  a  gland  causing  either  a 
plus  or  a  minus  reaction  may  therefore  evidence  itself  by  totally 
different  symptoms.  For  instance,  diminution  of  hypophysis 
activity  may  result  in  a  typical  dystrophia  adiposogenitalis. 


INSTINCTS  AND  EMOTIONS  247 

In  another  patient  there  may  be  diabetes  insipidus,  in  another 
amenorrhea  without  adiposity.  The  hypophysis,  when  hyper- 
active, may  produce  acromegaly,  dysmenorrhea,  metrorrhagia, 
fibromyomatous  growths,  fibrosis  uteri,  an  exaggerated  meta- 
boHsm  resulting  in  a  glycosuria,  or  the  symptoms  may  be  of  a 
general  nature  associated  with  excitability  or  irritability  of  the 
type  called  "hysterical," 

It  is  most  important  to  judge  the  endocrine  processes  of 
an  individual  at  any  age  from  childhood  up,  and  to  determine 
their  influence  on,  and  association  with,  instincts,  emotions, 
mental  and  psychic  reactions.  All  deviations  from  the  standard 
in  body  characteristics  are  due  to  over-  or  under-activity  of  the 
various  endocrines  or  to  the  numerous  and  innumerable  pos- 
sible variations  in  their  interrelation.  Normality  and  abnor- 
mality of  any  of  the  factors  concerned  with  a  child  or  adult 
are  due  to  heredity  and  to  inherited  instincts  and  emotions 
plus  the  play  of  the  endocrines. 

Normally  a  definite  balance  should  exist  between  the  in- 
terstitial and  glandular  structures  of  the  ovary;  between  the 
anterior  and  posterior  pituitary,  between  the  adrenal  cortex  and 
the  medulla.  The  balance,  as  well  as  the  activities  of  the  re- 
spective structures  represented  in  this  balance,  differs  in  the 
two  sexes,  with  the  testis  as  the  male  gonad. 

The  anterior  pituitary  is  vitally  concerned  with  body 
growth  and  mental  development.  It  is  associated  with  strength, 
large  or  broad  hands,  the  development  of  the  jaws  (we  speak 
of  a  firm  lower  jaw),  with  maturity  of  mind,  etc.,  and  its  func- 
tion is  more  in  evidence  in  men  than  in  women. 

Speaking  in  relative  terms  and  in  view  of  its  relation  to 
the  posterior  pituitary  it  is  a  male  gland  just  as  relatively 
speaking  the  thyroid  is  a  female  sex  gland. 

The  posterior  pituitary  related  to  the  uterus  and  genitalia 
(pituitrin,  for  instance)  plays  relatively  a  greater  role  in  its 
balance  with  the  anterior  lobe,  in  women  than  in  men.  Its 
action  is  associated  with  the  tender  emotions  and  with  the  sex 
instinct  in  women ;  and  so  far  as  the  tender  emotions  are  con- 
cerned plays,  of  course,  a  much  more  important  normal  role 


248  THE    ENDOCRINES 

in  women  than  in  men.  Relatively  speaking,  it  may  be  called 
a  female  gland.  It  is  related  to  fears,  phobias,  states  of 
anxiety,  etc. 

The  adrenal  structures  are  related  to  the  instincts  of  flight 
and  pugnacity  and  to  the  corresponding  emotions  of  fear  and 
anger.  The  adrenal  cortex  is  concerned  with  the  production 
of  hair  and  exerts  normally  a  greater  influence  in  many  phases 
in  the  male  than  in  the  female.  Good  adrenal  action  (cortex 
and  medulla)  is  essential  to  courage.  Poor  adrenal  action, 
especially  a  lack  of  balance  between  the  cortex  and  medulla 
wherein  the  cortex  plays  the  minor  role,  is  responsible  for  the 
emotions  of  fear,  for  cowardice,  for  anxiety.  The  adrenal 
cortex  is  more  of  a  male  than  a  female  portion  of  the  gland. 
The  medulla,  since  it  is  more  predominant  in  women,  is  there- 
fore partly .  responsible  for  their  being  more  "ernotional,"  as 
we  call  it. 

The  ovary  is  closely  related  to  the  posterior  pituitary  and 
to  the  adrenal  medulla.  This  combination  is  responsible  for 
the  characteristics  of  coyness  and  self-display.  She  is  not 
the  aggressor  in  the  sense  of  the  hunter  and  fighter,  she  is  the 
one  who  is  sought.  Since  the  anterior  pituitary  is  less  active, 
that  maturity  of  mind  and  what  we  call  wisdom,  greatly  de- 
pendent on  anterior  pituitary  action,  are  less  marked,  and  men 
have  produced  the  greatest  philosophers. 

The  male  gonads  are  responsible  for  the  sex  urge,  stimu- 
late the  adrenal  cortex  and  the  anterior  pituitary  more  than  do 
the  ovaries  in  women.  There  are,  therefore,  numerous  indi- 
cations for  the  administration  of  the  corresponding  extracts  in 
those  states  due  to  lack  of  sufficient  ardenal  cortex  or  anterior 
pituitary  activity.  Hence  man  is  the  fighter  and  the  hunter, 
his  sex  instinct  is  much  stronger,  he  is  the  aggressor  and  seeks 
the  woman. 

There  is  in  woman  no  such  mechanism  producing  the  con- 
sciousness of  sex  urge  as  man  has  in  the  testis,  vas  deferens, 
and  seminal  vesicles.  The  combination  of  testis  and  adrenal 
cortex  makes  man  more  brutal,  more  criminal  and  more  coarse. 
It  is  the  normal  action  of  the  anterior  pituitary  which  is  con- 


INSTINCTS  AND  EMOTIONS  249 

cerned  with  that  cerebral  trophic  stimulation  and  with  that 
maturity  of  mind  and  with  that  judgment  which  in  most  men 
act  as  restraining  factors  to  the  coarser  instincts.  A  normal 
associated  action  of  the  posterior  pituitary  has  a  like  moderat- 
ing action,  and  if  it  be  excessive  in  men,  even  though  it  does 
not  overbalance  the  action  of  the  anterior  pituitary,  such  men 
are  more  or  less  emotional,  have  tender  feelings,  are  fond  of 
children,  etc. 

The  thyroid  is  the  great  activator.  According  to  its 
action  it  stimulates,  understimulates  or  overstimulates  any  of 
the  functions,  instincts,  or  emotions  of  the  human  being.  It  is 
much  less  stable  and  much  more  frequently  overactive  in  women 
than  in  men.  It  is  the  great  fixer  of  impressions  for  all  things 
in  the  sphere  of  memory,  especially  for  all  things  not  associated 
with  those  instincts  and  emotions  which  are  specifically  asso- 
ciated with  the  activity  of  other  endocrines. 


CHAPTER   XIII 
MENTAL  AND  NERVOUS  DEFECTS 

"It  is  calculated  that  some  250,000  people  in  the  United 
States  are  insane.  One  of  every  five  men  discharged  from 
the  U.  S.  Army  for  disability  is  discharged  because  of  insanity, 
60  per  cent,  of  the  cases  being  dementia  precox," — Lewellys 
F.  Barker. 

The  mechanism  of  mentality  may  be  faulty  from  the  be- 
ginning or  it  may  be  made  faulty  by  bad  environmental  con- 
ditions. 

The  records  of  insanity,  imbecility,  feeble-mindedness,  and 
other  forms  of  nervous  and  mental  defects  are  truly  startling. 
In  general,  insanity  is  a  degenerative  process.  It  is  question- 
able if  there  is  a  single  genuine  case  on  record  where  a  normal 
child  has  been  borne  from  a  union  of  two  imbeciles.    (Guyer.) 

Dr.  Charles  Gorst,  Superintendent  at  the  Mendota  Hos- 
pital, says :  "No  one  doubts  for  a  moment  that  defective 
mental  conditions  are  transmitted  from  parent  to  child  as 
surely  as  the  physical  defects  and  deformities." 

One  serious  drawback  in  making  a  study  of  inheritability 
in  insanity  and  other  nervous  disorders  is  that  so  far  we  have 
dealt  mainly  with  mass  effects  rather  than  specific  neuroses. 
But  when  the  latter  is  attempted  we  are  confronted  by  the 
fact  that  there  are  various  intergradations  of  the  recognized 
types  of  defects,  that  because  of  varying  degrees  of  defect 
in  the  same  type  a  standard  is  hard  to  establish,  and  that,  above 
all,  what  appears  as  a  specific  mental  malady  in  one  individual 
may  crop  out  in  his  descendants  in  an  entirely  different  guise. 
Feeble-mindedness  vs.  Insanity. 

Authorities  make  a  sharp  distinction  between  insanities 
on  the  one  hand  and  feeble-mindedness  on  the  other.  Accord- 
ing to  Goddard,  not  only  is  there  no  close  relationship  between 
the  two  conditions,  but  in  reality  they  stand  at  opposite  ends 
of  the  psychical  scale.  In  general,  insanity  is  a  degenerative 
process,  whereas  feeble-mindedness  is  an  arrest  of  develop- 

250 


MENTAL  AND   NERVOUS   DEFECTS  251 

ment.  In  the  first  case  the  victim  loses  part  of  the  mentality 
he  once  had,  in  the  second  he  stops  short  of  normal  develop- 
ment.     ( Guyer. ) 

The  commonest  manifestations  of  insanity  are  undue 
depression,  apathy,  excitement,  instability,  obsessions,  halluci- 
nations, and  delusions. 

In  general,  there  is  more  doubt  about  the  inheritability 
of  some  of  the  insanities  than  about  cases  of  mental  deficiency. 
A  neuropathic  person  who  manifests  certain  anti-social  ac- 
tivities is  sure  to  be  classed  as  insane,  whereas  another  indi- 
vidual with  the  same  diathesis  in  a  less  degree  might  pass  un- 
recognized. It  is  almost  impossible  in  some  instances  to  tell 
just  where  the  border  line  between  a  neuropathic  and  a  normal 
constitution  lies.  Many  of  the  idiosyncrasies  of  the  insane 
indeed  are  merely  exaggerations  of  characteristics  seen  in 
normal  people.  Recent  studies  of  the  psychology  of  the 
insane  show  that  most  of  their  hallucinations  and  delusions 
are  closely  related  to  some  previous  mental  experience  they  had 
before  becoming  insane.  And  it  has  been  found  that  the 
surest  means  toward  removing  the  obsessions  of  the  patient 
in  curable  cases  is  to  ferret  out  these  earlier  experiences  and 
correct  the  zurong  impressions  concerning  them.  Certain 
critical  periods  of  life,  such  as  puberty,  pregnancy,  and  the  close 
of  sexual  life,  are  particularly  lil<ely  to  test  out  the  mentally 
unstable,  although  such  individuals  may  have  maintained 
normal  mental  balance  up  to  the  crisis  in  question.    (Guyer.) 

Manic  depressive  psychoses  and  dementia  precox,  in  the 
order  named,  represent  the  largest  number  of  admissions  to 
hospitals  for  the  insane. 

Kraepelin  states :  "The  psychopathic  charge  of  a  family 
may  reveal  itself  not  only  by  the  appearance  of  mental  disor- 
ders but  also  by  other  forms  of  manifestation.  Here  belong, 
before  all,  those  diverse  slighter  deviations  from  mental  health 
which  go  to  make  up  the  border-line  of  insanity :  nervousness, 
states  of  anxiety  and  compulsion,  constitutional  depressions, 
slight  hysterical  disorders  and  forms  of  feeble-mindedness,  tics ; 
also  odd  characters,  peculiarities  in  modes  of  living,  criminal 


252  THE    ENDOCRINES 

tendencies,  lack  of  self-control,  intemperance,  love  of  adven- 
ture, mendacity,  suicide  on  an  inner  basis." 

Church  and  Peterson,  in  Nervous  and  Mental  Diseases, 
state:  "In  determining  the  factor  of  heredity  we  must  not 
be  content  with  ascertaining  the  existence  of  psychoses  in  the 
ascendants,  but  must  seek  by  careful  interrogation  of  various 
members  of  the  family  for  some  of  the  hereditary  equivalents, 
such  as  epilepsy,  chorea,  hysteria,  neurasthenia,  somnambulism 
migraine,  organic  diseases  of  the  central  nervous  system,  crim- 
inal tendencies,  eccentricities  of  character,  drunkenness,  etc., 
for  these  equivalents  are  interchangeable  from  one  generation 
to  another,  and  are  simply  evidence  of  instability  of  the  nervous 
system.  It  is  the  unstable  nervous  organization  that  is  in- 
herited, not  a  particular  neurosis  or  psychosis." 

A  number  of  psychiatrists  and  investigators  of  the  in- 
heritance of  insanities  (Rudin,  Lunborg,  Davenport,  Rosanoff, 
Jolly)  concur  in  the  opinion  that  manic-depressive  insanity,  de- 
mentia precox  and  allied  psychopathic  conditions  tend  to  occur 
after  the  manner  of  a  Mendelian  recessive.  On  the  other  hand, 
such  maladies  as  Huntington's  chorea  are  transmitted  as  a 
dominant  and  in  all  probability  at  least  half  of  the  children  of 
an  afflicted  individual  will  inherit  and  manifest  the  defect.  As 
Dr.  Wilmarth  says :  "Alental  accident  may  occur  in  any  fam- 
ily, but  it  is  rarely  that  a  second  case  occurs  unless  there  is  a 
tendency  to  nerve  degeneracy." 

Grades  of  Feeble-Mindedness. 

As  to  the  various  grades  of  feeble-mindedness,  while  no 
sharp  lines  of  demarcation  can  be  drawn,  a  rough  and  ready 
test  usually  applied  is  the  relative  ability  of  such  subnormal 
individuals  to  take  care  of  themselves.  In  all,  the  conditions 
exist  from  birth  or  shortly  after.  Idiots  are  such  defective 
individuals  as  are  unable  to  take  care  of  themselves  even  in  the 
matter  of  guarding  against  common  physical  dangers.  Their 
mentality  does  not  progress  beyond  that  of  a  two-year-old 
child.  Imbeciles  are  able  to  take  care  of  themselves  in  the 
cruder  physical  ways,  but  are  unable  to  earn  their  living.  Their 


MENTAL  AND   NERVOUS   DEFECTS  253 

mental  age  ranges  from  three  to  seven  years  inclusive.  Morons, 
or  the  "feeble-minded,"  in  a  more  specific  usage  of  the  term, 
can  under  proper  direction  become  more  or  less  self-support- 
ing, but  they  are,  as  a  rule,  incapable  of  undertaking  affairs 
which  demand  judgment  or  involve  unrestricted  competition 
with  normal  individuals.  Their  intelligence  ranges  with  that 
of  children  from  seven  to  twelve  years  of  age.  The  last  class 
grades  up  insensibly  into  the  shiftless,  ne'er-do-well  types  which 
exist  in  every  community.  It  is  the  hordes  of  the  feeble- 
minded in  the  restricted  sense  that  afford  our  most  serious 
problems  today.  The  idiot  and  the  imbecile  are  usually  early 
and  easily  recognized  and  kept  more  or  less  under  restraint,  but 
the  higher  grades  of  feeble-minded,  the  so-called  moron  type, 
can  be  detected  often  only  by  carefully  devised  tests.  (Guyer.) 
All  facts  point  to  the  conclusion  that  most  mental  de- 
ficiency is  strongly  inheritable  and  that  the  majority  of  our 
defectives  of  this  type  come  from  degenerate  stocks. 

"We  now  know  that  65  per  cent,  of  these  children 
(Goddard,  Vineland,  N.  J.)  have  inherited  the  condition  and 
that  if  they  grow  up  and  marry  they  will  transmit  the  same 
condition  to  their  offspring.  Indeed,  we  know  that  this  class 
of  persons  is  increasing  at  an  enormous  rate  in  every  com- 
munity and  unless  we  do  something  to  stop  this  great  stream 
of  bad  protoplasm  we  shall  some  day  be  swamped  in  a  sea  of 
degeneracy." 

Dr.  A.  C.  Rogers,  Superintendent  of  a  school  for  feeble- 
minded in  Alinnesota,  says :  "We  have  no  survey  of  mentality 
in  this  country  except  in  very  small  areas,  but  probably  about 
65  per  cent,  of  the  feeble-minded  children  that  we  know  of  are 
feeble-minded  from  heredity;  that  is,  they  come  from  families 
in  which  there  is  much  feeble-mindedness,  usually  associated 
with  various  neuroses  or  psychoses.  There  are  about  35  per 
cent.,  approximately,  that  are  acquired  cases. 

On  the  other  hand,  as  our  data  show,  there  remain  about 
one-third  of  the  mentally  deficient  to  be  accounted  for  on 
other  than  a  basis  of  heredity. 


254  THE    ENDOCRINES 

Mongolianism  does  not  seem  to  be  hereditary,  although 
it  is  usually  congenital, 

Wilmarth  says :  "Epilepsy  and  mental  deficiency  are  as 
closely  related  as  branches  on  the  same  tree.  So  small  a  per- 
centage of  epileptics  maintain  normal  mental  actions  as  hardl) 
to  be  worth  consideration,  even  those  who  retain  a  normal 
mind  in  the  early  stages  of  the  disease  almost  infallibly  be- 
come imperfect  later." 

Goddard,  one  of  the  best  authorities  on  the  heredity  oi 
feeble-mindedness,  is  inclined  to  regard  the  condition  as  a 
unit  character,  "due  either  to  the  presence  of  something  which 
acts  as  an  inhibitor,  or  due  to  the  absence  of  some  stimulus 
which  sends  the  normal  brain  on  to  further  development/' 

Supposing  nervous  defects  finding  expression  in  feeble- 
mindedness, epilepsy,  and  related  conditions,  to  act  as  a  Men- 
delian  recessive,  then  the  marriage  of  one  such  defective  with 
another  should  yield  only  mentally  enfeebled  offspring.  How 
nearly  this  expectation  may  be  realized  is  seen  from  the  fol- 
lowing examples :  In  an  extensive  study  of  Feeble-minded- 
ness, Dr.  Henry  H.  Goddard  points  out  that  out  of  482  children 
with  both  parents  feeble-minded,  all  but  six  were  feeble- 
minded.    (Guyer.) 

Davenport  points  out  that  not  infrequently  two  deaf-mutes 
whose  defects  are  due  to  different  causes  may  have  normal 
children. 

A  mating  between  a  feeble-minded  person  and  one  of 
perfectly  normal  stock  will  apparently  result  in  normal  chil- 
dren, although  they  will  be  carriers.  There  is  some  evidence, 
however,  that  such  carriers  may  occasionally  show  "taints"  of 
abnormality  in  the  form  of  migraine  (nervous  sick  headaches), 
alcoholism,  queerness,  violent  temper,  etc. 

There  is  considerable  evidence  that  many  apparently  nor- 
mal individuals  of  our  average  population  are  in  reality  car- 
riers of  some  form  of  neuropathic  defect,  some  authorities  plac- 
ing the  proportion  provisionally  at  over  thirty  per  cent. 

Importance  of  Early  Diagnosis  of  Insanity.     (Guyer.) 
Most  of  the  insane  who  recover  usually  do  so  within  a 


MENTAL  AND   NERVOUS   DEFECTS  255 

few  months  of  their  first  ahenation,  hence  the  importance  of 
losing  no  time  in  detecting  the  condition  and  securing  early 
treatment.  It  is  now  well-known  that  many  cases  of  chronic 
insanity  may  be  measurably  improved  under  the  care  of  a 
psychiatrist  by  systematic  re-education,  especially  in  industrial 
lines. 

There  is  little  doubt  that  the  tendency  is  to  under-estimate 
rather  than  over-estimate  the  factor  of  heredity  in  insanity. 
Many  cases  said  to  be  "caused"  by  mental  strain, — such  as 
those  occasioned  by  domestic  infelicities,  business  reverses, 
and  the  like, — should  in  all  probability  be  fundamentally  at- 
tributed to  something  far  more  deep-seated  than  the  more 
obvious  cause.  In  many  such  instances  there  is  little  doubt 
that  an  inherent  weakness  in  mental  make-up  exists  which 
predisposes  the  individual  toward  mental  breakdown. 

Undoubtedly  certain  infectious  diseases,  arterio-sclerosis, 
various  poisons  in  the  blood,  child-birth,  and  similar  influences 
often  enter  as  contributory  factors. 
Crime  and  Delinquency. 

While  there  is  no  longer  a  reasonable  doubt  about  such 
nervous  disorders  as  epilepsy,  feeble-mindedness,  and  cer- 
tain forms  of  insanity  being  rooted  largely  in  ancestral  taints, 
the  degree  to  which  crime  or  delinquency  is  based  on  heredity 
is  far  more  questionable. 

Beyond  doubt  a  considerable  proportion  of  crime  and 
degeneracy  is  due  in  a  large  measure  to  innate  inclination, 
but  with  just  as  little  doubt  much  is  the  effect  mainly  of  vicious 
habits  acquired  through  an  unwholesome  environment. 

The  conviction  is  steadily  growing  among  students  of 
heredity  that  a  considerable  amount  of  crime,  gross  immoral- 
ity and  degeneracy  is  due  at  bottom  to  feeble-mindedness 
and  that,  therefore,  if  we  can  once  eliminate  feeble-mindedness 
these  vicious  accompaniments  will  at  the  same  time  in  equal 
measure  disappear.  Goddard  is  convinced  that  a  large  pro- 
portion of  the  delinquent  girls  who  fill  our  reformatories  are 
actually  feeble-minded.  They  are  often  the  higher  grade 
or  moron  type,   and  their  mental  condition  remains  unsus- 


256  THE    ENDOCRINES 

pected  because  they  have  never  been  thoroughly  tested  in  this 
respect.  One  great  difficulty  in  identifying  the  high-grade 
morons  who  are  a  bountiful  source  of  our  criminals  is  our 
almost  universal  failure  to  recognize  that  a  memory  test  alone 
is  not  sufficient  to  determine  the  mental  responsibility  of  an 
individual. 

Davenport :  "We  have  certain  methods  of  testing  whether 
it  is  bad  environment  or  bad  breeding  which  produced  these 
people.  Some  of  the  children  have  been  taken  at  an  early 
age  and  'placed  out.'  We  have  traced  their  subsequent  his- 
tory. In  most  cases  they  have  turned  out  well,  but  it  is  also 
true  that  some  of  the  children  who  remained  at  home  in  bad 
environment  turned  out  well." 

Wilmarth :  "In  no  place  is  this  subject  of  the  power  of 
heredity  in  relation  to  environment  so  easily  studied  as  among 
our  children.  A  group  of  many  little  children  came  to  us  from 
the  state  school,  being  untrainable  there.  Each  one  has  lived, 
eaten,  and  slept  among  the  others,  and,  so  far  as  we  know, 
with  but  one  exception,  those  of  vicious  parentage  have  turned 
instinctively  to  vicious  traits  by  preference,  while  those  of 
simple  but  honest  stock  do  evil  things  only  under  strong  temp- 
tation, and  do  not  persist  in  them  after  the  zurong  is  pointed 
out" 

Healy:  "Such  factors  as  immorality  or  constant  quarrel- 
ing of  parents,  bad  companions,  lack  of  parental  control,  de- 
fective sense  organs,  debilitating  habits,  lack  of  healthy  mental 
interests,  and  a  host  of  other  environmental  factors  are  not 
infrequently  sufficient  in  themselves  to  develop  delinquency  in 
the  absence  of  inherited  deficiency." 

Karl  Pearson  concludes  ''that  it  is  a  conservative  estimate 
to  regard  heredity  as  at  least  five  or  ten  times  as  important  as 
environment  in  the  development  of  the  individual" 


CHAPTER   XIV 
MENTAL  DEFICIENCY  AND  CRIMINALITY 

(SCHLAPP) 

Four  hundred  years  ago,  no  less  a  thoughtful  and  scholarly 
personage  than  Martin  Luther  recommended  that  a  twelve- 
year-old  child  be  drowned  and  asked  that  prayers  be  offered 
to  cleanse  its  soul  of  a  devil.  Coming  nearer  to  our  own  time, 
our  Puritan  ancestors  burned  scores  of  persons  so  unfortunate 
as  to  be  believed  possessed  of  devils. 

We  know  now  that  the  child  who  almost  fell  victim  to 
Luther's  ignorance,  and  many  of  the  persons  burned  by  our 
forefathers  as  witches  were  guilty  of  no  worse  ofifense  than 
feeblemindedeness.  We  look  back  with  wonder  on  the  ig- 
norance of  these  times ;  but  our  own  attitude  as  evidenced  by 
our  present  unenlightened  methods  of  dealing  with  mental 
defectives,  particularly  those  whose  defectiveness  has  taken  a 
criminal  trend,  shows  in  us  a  pitifully  slow  evolution  in  ascer- 
taining the  causes  of  abnormality  in  human  beings. 

We  still  judge  criminals  and  delinquents  by  their  acts 
alone  and  to  a  large  extent  dispose  of  them  legally  on  this  basis. 
The  general  public,  and  even  the  courts,  believe  that  a  person 
of  normal  intellect  can  control  his  actions  and,  consequently, 
that  the  actions  of  any  person  of  normal  intellect  are  premedi- 
tated, or  at  least  controlled  completely  by  the  intellectual  men- 
tal make-up,  and  that  therefore  the  person  is  responsible. 

In  the  light  of  well  established  facts,  known  to  psy- 
chiatrists for  the  last  half  century,  this  method  of  placing  re- 
sponsibility for  criminal  acts  is  basically  erroneous  and  should 
be  revised.  We  must  learn  to  comprehend  many  abnormal 
classes  hitherto  unrecognized  by  society  as  subjects  for  study, 
control  or  aid. 

There  is  no  question  of  altruism  involved;  a  proper  un- 
derstanding and  attitude  toward  these  people  who  have  no 
innate  power  of  adjustment  to  their  environment  will  make 
every  home  and  family  more  nearly  safe,  the  state's  taxes  will 
'7  257 


258  THE    ENDOCRINES 

be  lessened  and  future  generations  will  be  infinitely  better 
equipped  for  the  struggle  of  life.  Too  much  stress  cannot  be 
laid  on  the  broad  scope  of  influence  which  mental  defectives 
exercise  on  everyday  affairs  and  the  consequent  tremendous 
interest  the  problem  should  have  for  "the  man  on  the  street." 

You  are  acquainted — perhaps  too  well — with  the  boy 
who,  surrounded  by  an  affectionate  family  in  a  home  of  ease, 
runs  away  repeatedly,  undergoes  unnecessary  hardships  and 
when  brought  back  can  never  give  any  explanation  for  his  acts 
except  that  he  "just  wanted  to  get  away."  You  doubtless  also 
have  come  Into  contact  with  those  other  well-known  types  of 
juvenile  delinquency — children  who  lie  and  practice  petty  thiev- 
ery from  their  earliest  years,  later  forge  checks  and  generally 
involve  their  families  in  serious  situations,  and  in  whose 
genealogical  history  there  is  no  discernible  trace  of  family  pro- 
pensity for  similar  actions.  There  is  also  the  brilliant  youth 
with  every  promise  of  success  and  an  intellect  capable  of  splen- 
did achievement,  who  never  quite  gets  a  grip  on  himself,  who 
follows  the  line  of  least  resistance,  becomes  a  drifter  and 
eventually  is  classed  as  a  confirmed  failure. 

In  another  class  are  the  thousands  of  tramps,  possessing 
what  is  commonly  termed  an  aversion  to  work,  who  form  an 
almost  alien  stratum  of  society,  useless  to  themselves,  and  liable 
at  any  time  to  become  a  menace  to  the  communities  through 
which  they  pass. 

Still  another  class  which  we  have  not  understood  is  com- 
posed of  those  unfortunate  persons  who  because  of  abnormal 
emotional  trends  or  phobias  are  forced  to  commit  acts  over 
which  they  have  no  intellectual  control — such  persons  as,  enter- 
ing a  subway  or  crowded  hall,  are  subject  to  seizure  by  an 
overwhelming  sense  of  oppression  and  an  irresistible  desire  to 
rush  out  into  the  open,  which  they  frequently  do. 

Even  without  the  direct  proof  now  offered  by  medical 
science,  it  should  be  obvious  to  any  thinking  person  that  in 
all  these  cases  there  is  something  wrong  in  the  delicate  mental 
mechanism  which  controls  the  destinies  of  these  people.     And 


MENTAL  DEFICIENCY   AND   CRIMINALITY  259 

there  is  just  as  much  evidence  that  these  mental  disturbances 
are  directly  traceable  to  a  physical  cause. 

Our  present  methods  of  handling  criminals,  not  to  men- 
tion our  attitude  toward  all  the  classes  of  abnormalities  men- 
tioned heretofore,  show  an  absolute  lack  of  recognition  of  any 
connections  between  their  acts  and  their  mental  and  physical 
deformities. 

The  first  thing  to  be  understood  about  these  people  is  the 
fact  that  the  pathological  criminal  or  mental  defective  is  un- 
able to  adjust  himself  normally  to  his  environment  for  the  very 
important  reason  that  the  motivating  activities  of  his  brain  are 
seriously  disturbed. 

To  understand  such  disturbances,  it  is  first  necessary  to 
know  that  the  motivating  activities  of  the  brain  are  regulated 
entirely  by  two  antecedent  processes — the  intellectual  and  the 
emotional,  or  affective,  activities.  If  these  two  processes  are 
well  balanced,  the  motivating  center  will  be  stimulated  in  such 
a  way  as  to  make  the  individual  adjust  himself  normally  to 
his  environment.  Should  this  balance  between  the  intellectual 
and  the  emotional  processes  be  seriously  disturbed,  however, 
then  it  will  be  impossible  for  the  individual  to  adjust  himself 
normally  and  he  will  perpetrate  acts  which  often  are  illegal 
and  always  abnormal. 

The  mind  is  thus  a  duality,  and  not  a  unity,  and  it  must 
be  understood  as  such  if  we  are  to  gain  a  knowledge  of  its  con- 
tents which  will  lead  to  a  correct  diagnosis  of  the  conditions 
responsible  for  the  maladjustment  of  individuals  to  their  sur- 
roundings. 

The  intellectual  side  of  the  mind  is  that  through  which  we 
receive  perceptions  and  form  conceptions.  Our  standards  of 
judgment  are  born,  and  the  actual  processees  of  reasoning  take, 
place,  in  this  department  of  the  mind. 

Perceptions  are  the  elementary  mental  impressions  re- 
ceived through  what  commonly  are  called  the  five  senses.  Con- 
ceptions are  the  pictures  the  mind  registers  and  files  away  of 
the  things  perceived. 


260  THE    ENDOCRINES 

For  instance,  a  child  sees  a  radiator.  That  initial  im- 
pression of  color  and  shape  is  a  percept,  as  is  the  impression  of 
the  sound  the  radiator  makes.  One  perception  goes  into  the 
brain  through  the  projection  centers  of  the  visual  nerves,  the 
other  through  the  projection  centers  of  the  auditory  nerves. 
Together,  the  two  percepts  rush  to  the  association  centers  of 
the  brain  and  a  concept  of  the  radiator  is  formed. 

The  child,  still  moved  only  by  the  intellect,  is  curious  con- 
cerning the  radiator — wants  to  know  more  about  it.  He 
reaches  out  and  touches  the  hot  metal.  Another  percept  reaches 
his  brain  at  once,  the  percept  of  pain,  traveling  to  the  pain 
centers.  This  percept  goes  also  to  the  association  centers  and 
makes  more  complete  the  concept  of  the  radiator.  It  is  a 
thing  which  has  a  certain  appearance,  makes  a  certain  sound 
and  produces  a  certain  variety  of  pain.  The  visual  percept 
and  the  sound  percept  of  the  radiator  may  not  have  awakened 
any  wave  of  feeling  in  the  child's  brain  of  which  he  was  con- 
scious, but  when  the  percept  of  pain  was  added  to  the  mental 
picture  of  the  radiator,  then,  aside  from  the  actual  pain  im- 
pression, a  wave  of  feeling  which  was  distinctly  one  of  dis- 
pleasure was  awakened  in  the  child's  mental  make-up. 

From  that  time  on,  reception  into  the  child's  intellect  of 
any  of  the  three  percepts  will  rebuild  the  completed  concept, 
which  will  cause  the  emotional  side  of  his  mind  to  experience 
again  the  emotion  of  fear.  The  radiator  may  be  silent,  but  the 
mere  sight  of  it  reawakens  the  concept  and  the  child  will  not 
touch  it. 

Something  else  may  make  a  similar  sound.  Until  de- 
veloped reasoning  power  teaches  him  better,  the  child  associates 
the  sound  with  the  hot  radiator  and  will  not  touch  the  object 
which  produced  the  concept-forming  noise.  If  he  should  run 
against  something  hot  in  the  dark,  the  child  will  think  of  the 
radiator,  provided  he  has  not  been  burned  by  something  else. 
In  each  case,  the  reawakened  concept  would  arouse  in  the  emo- 
tional centers  of  the  child's  mind  the  emotion  of  fear  and  that 
emotion  would  make  him  avoid  the  real  or  fancied  danger. 


MENTAL  DEFICIENCY   AND   CRIMINALITY  261 

Through  this  simple  illustration,  we  see  the  relation  be- 
tween the  two  departments  of  the  mind  and  the  functional 
activities  of  each  department. 

A  disturbance  in  brain  activity  seriously  involving  either 
the  intellectual  or  the  emotional  centers,  or  both  of  them,  re- 
sults in  what  is  known  as  mental  defectiveness.  To  understand 
these  disturbances,  it  is  necessary  to  examine  the  life  processes 
of  the  cells  of  which  the  brain,  like  the  rest  of  the  body,  is 
composed. 

We  know  that  the  life  processes  of  the  brain  cells  consist 
of  three  kinds  of  activity — the  nutritive,  the  formative,  and 
the  functional.  Through  the  nutritive  processes,  the  cells  take 
in  substances  from  the  surrounding  medium  and  store  them 
as  potential  energy.  The  formative  activity  is  the  process  of 
cell-division,  or  physical  growth.  The  functional  activity  is 
the  process  whereby  a  cell,  responding  to  a  stimulus  from 
without,  performs  some  act — the  contraction  of  muscle  cells, 
the  secretion  of  gland  cells,  the  reaction  of  nerve  cells,  and  so 
forth. 

The  potential  energy  stored  by  the  nutritive  activity  is 
drawn  upon  constantly  by  the  formative  and  the  functional 
activities,  the  two  being  rivals.  Before  birth,  the  cells  of  the 
body  are  chiefly  engaged  in  formative  activity,  while  from 
birth  on  the  functional  activity  rapidly  increases  until  it  be- 
comes the  predominating  process  in  adult  life. 

So,  if  the  chemical  substances  necessary  for  certain  cells 
are  not  supplied  sufficiently  before  birth,  or  in  early  life,  the 
growth  of  the  organ  those  cells  compose  is  affected.  This 
results  in  physical  defectiveness,  or  in  mental  defectiveness  if 
the  brain  is  involved.  The  same  lack  of  nourishment  in  later 
life  will  affect  the  cells'  functional  activity,  or  their  power  to 
act. 

A  division  of  mental  defectiveness  into  three  groups  pro- 
vides the  best  working  basis  for  grasping  the  intricacies  of  the 
particular  branch  in  which  we  are  interested. 

In  order  immediately  to  dispose  of  it,  the  Traumatic  Type 
should  compose  the  first  group.     This  includes  all  those  cases 


262  THE    ENDOCRINES 

in  which  the  defectiveness  is  due  to  a  definite  physical  injury 
to  the  brain  before  birth,  at  birth,  or  in  early  life. 

Likewise,  we  should  dispose  of  the  Formative  Type,  or 
cases  in  which  the  brain  in  whole  or  in  part  has  not  developed 
because  of  improper  cell  g-rowth. 

The  third,  and  to  us  the  most  important  group  because 
it  is  amenable  to  treatment,  is  the  Functional  Type.  In  cases 
of  this  type,  the  brain  cells  are  not  lacking  in  number,  but 
there  is  a  disturbance  in  the  proportion  of  the  different  chemical 
factors  in  the  surrounding  medium  from  which  the  cells  draw 
their  necessary  potential  energy  and  activating  substances,  and 
therefore  the  cells  do  not  react  normally  to  stimulation. 

The  point  at  which  an  incoming  impulse  will  explode  the 
unstable  protoplasm  within  the  cell — thus  turning  the  poten- 
tial energy  therein  into  kinetic  energy — and  release  an  outgoing 
impulse  is  called  the  threshold  of  functional  activity.  If  there 
exists  a  normal  chemical  balance  in  the  blood,  and  therefore  in 
the  cell,  this  threshold  will  be  normal.  If  there  exists  a  chem- 
ical unbalance  or  disturbance,  then  the  threshold  may  be  either 
raised  or  lowered. 

Under  conditions  of  chemical  disturbance,  this  threshold 
may  figuratively  be  compared  to  that  of  various  grades  of  ex- 
plosives. Gunpowder,  for  instance,  is  fairly  stable,  dynamite 
explodes  more  easily,  and  TNT  has  a  still  lower  threshold. 

It  must  be  borne  in  mind  that  a  normal  threshold  has  a 
certain  more  or  less  constant  level.  If  the  threshold  is  raised 
above  this  level,  the  cell  response  is  less  active;  indeed,  the 
threshold  may  even  be  raised  to  the  point  where  the  cell  will 
not  respond  at  all  to  outside  stimulation. 

In  a  similar  way,  the  lowering  of  the  threshold  below  the 
normal  level  will  bring  about  a  condition  in  which  the  cell  will 
respond  to  impulses  that  ordinarily  would  not  cause  a  reaction. 

One  of  the  chief  causes  of  a  lowered  threshold  is  a  dis- 
turbance of  the  internal  secretions.  For  example,  a  lowered 
threshold  is  found  in  persons  in  whom  the  thyroid  substances 
of  the  body  are  increased.  A  marked  instability  of  the  cells  is 
affected  and  explosive  reactions  will  result  from  incoming  im- 


MENTAL  DEFICIENCY  AND  CRIMINALITY  263 

pulses  which  in  normal  circumstances  would  hardly  produce 
any  reaction.  Likewise,  when  the  thyroid  substance  is  deficient, 
a  person  will  not  respond  normally  and  keenly  to  an  incoming 
impulse  which  in  normal  circumstances  would  cause  a  response, 
because  the  threshold  of  functional  activity  has  been  raised. 

What  is  true  of  the  thyroid  is  also  true  of  the  suprarenal, 
pituitary,  and  other  gland  secretions,  though  their  action  has 
not  yet  been  as  fully  determined  as  that  of  the  thyroid. 

Interference  with  the  functional  activity  of  the  cells  and 
emotional  instability  may  also  result  from  the  introduction  of 
foreign  toxins  into  the  system.  These  toxins  may  not  only 
affect  the  threshold  of  functional  activity  but  may  also  create 
a  disturbance  of  the  internal  secretory  glands. 

Both  toxins  and  the  chemicals  in  the  blood  act  selectively 
upon  the  various  centers  of  the  nervous  system.  Ether,  for 
example,  selectively  involves  the  highest  centers  of  cerebration, 
raising  the  threshold  to  such  a  point  that  incoming  impulses 
cause  no  reaction,  thus  producing  unconsciousness ;  but  at  the 
same  time  it  does  not  equally  affect  the  nerve  cells  of  the 
respiratory  and  circulatory  centers,  thus  permitting  those  cen- 
ters to  respond  to  incoming  impulses  and  allowing  the  person 
to  live. 

So  we  see  that  a  chemical  disturbance  in  the  blood  may 
affect  the  functional  activity  of  one  or  more  centers  of  the 
brain,  making  them  either  more  unstable,  or  stable.  This 
brings  us  to  consideration  of  the  effect  of  such  disturbances 
upon  our  actions. 

Perceptions  and  conceptions,  formed  in  the  intellectual 
side  of  the  brain,  send  impulses  to  the  emotional  side.  If  these 
impulses  pass  the  threshold  of  functional  activity  in  the  emo- 
tional centers,  a  wave  of  feeling,  or  emotion,  results.  If, 
through  a  chemical  disturbance  of  the  blood,  the  threshold  of 
functional  activity  of  the  cell  groups  of  the  emotional  centers 
has  been  selectively  lowered,  the  wave  of  feeling  may  be  so 
strong  as  to  wipe  out  entirely  all  restraining  influences  coming 
from  the  intellectual  side  of  the  brain,  and  make  the  emotional 
the  motivating  impulse  in  the  person's  mental  make-up. 


264  THE    ENDOCRINES 

In  persons  of  normal  emotional  make-up  unreasonable 
reactions  may  be  prevented  through  inhibitions  coming  from 
the  intellectual  side  of  the  brain.  In  persons  of  unstable  emo- 
tional make-up,  intellectual  inhibitions  may  be  felt,  but  if  the 
wave  of  feeling  is  strong  enough  the  person  may  not  even  be 
conscious  of  the  inhibition.  The  wave  of  feeling  simply  wipes 
out  the  mental  attributes  of  judgment,  of  right,  and  of  thought 
of  consequences  and  precipitates  the  impulsively  inspired  action. 

The  person  so  unfortunate  as  to  be  unstable  emotionally 
is  not  only  exposed  to  these  impulses,  such  as  anger  impulses, 
sex  impulses,  etc.,  and  to  the  consequences  arising  from  them, 
but  any  succession  of  exposures  is  likely  to  build  up  phobias 
and  trends  which  may  make  him  lose  complete  intellectual  con- 
trol of  himself  whenever  the  impulse  comes  to  him. 

These  pathological  waves  of  feeling,  aroused  by  a  per- 
cept or  a  concept,  may  be  either  negative  or  positive.  A 
negative  wave,  which  would  be  a  displeasurable  one,  may  create 
in  the  brain  an  unreasoning  fear  of  some  object  or  condition 
which  will  impel  him  against  all  his  intellect  to  some  unreason- 
able or  perhaps  ludicrous  action,  though  one  usually  not  of  a 
criminal  type.  A  positive,  or  pleasurable  wave,  on  the  other 
hand,  may  create  in  the  brain  a  trend  which  will  impel  a  man 
upon  re-experiencing  the  concept  to  an  action  which  is  unrea- 
sonable and  often  criminal. 

The  boy  in  a  comfortable  home  may  be  inflicted  through 
unstable  emotional  make-up  with  a  trend  for  running  away 
and  undergoing  all  sorts  of  unnecessary  hardships;  the  boy 
who  has  all  his  desires  gratified  may  be  inflicted  with  a  trend 
to  steal  and  eventually  becomes  a  forger  and  thief;  men  of 
good  training  and  intellect  may  come  to  commit  heinous 
crimes;  girls  of  good  family  and  training  may  be  led  to  the 
streets,  and  our  reformatories,  jails,  and  corrective  institutions 
become  constantly  more  crowded  with  persons  who  never 
should  have  been  sent  to  them  either  in  justice  to  themselves 
or  to  the  rest  of  the  community. 

It  should  be  emphasized  that  persons  impelled  by  over- 
powering impulses  that  are  not  criminal  have  nothing  to  gain 


MENTAL  DEFICIENCY   AND   CRIMINALITY  265 

by  their  unusual  actions;  instead,  they  more  often  have  much 
to  lose  by  resulting  ludicrous  situations.  Even  those  impelled 
to  steal  may  in  the  next  moment  give  away  what  they  have 
taken.  It  is  not  as  though  they  act  for  their  personal  benefit — 
they  simply  cannot  help  it. 

Instances,  no  two  alike,  could  be  cited  indefinitely,  and 
the  encouraging  part  of  it  is  that  most  of  these  people  can  be 
relieved  if  not  cured. 

It  is  apparent  that,  if  through  tests  we  can  find  a  chemical 
disturbance  in  the  blood  of  persons  of  obvious  unstable  emo- 
tional make-up,  we  can  lay  hands  on  the  seat  of  the  disturbance 
in  most  cases  and  help  them.  In  many  of  the  cases  examined 
at  the  Post-Graduate  Hospital,  chemical  disturbance  was 
found,  and  in  more  than  half  of  these  cases  the  cause  was 
traced  directly  to  certain  of  the  internal  secretory  glands. 

This  has  been  accomplished  through  only  a  few  blood 
tests  which  have  been  evolved.  New  tests  are  being  worked 
on  constantly,  and  the  hope  is  to  narrow  the  field  until  we  can 
lay  a  finger  on  the  seat  of  all  emotional  disturbances. 

The  large  number  of  cases  examined  have  given  sufficient 
data  to  show  a  connection  between  emotional  types  and  a  dis- 
turbing of  definite  glands,  and  the  attempt  now  is  to  establish 
a  definite  cause  for  each  criminal  type. 

Necessarily  the  treatment  varies  in  every  case.  It  consists 
in  most  cases  in  raising  the  threshold  of  functional  activity  by 
chemical  substances  which  prevent  excessive  stimulation  of  the 
internal  secretory  glands  and  by  neutralizing  the  effects  of  cer- 
tain excessive  secretions  by  introducing  counterbalancing  sub- 
stances. 

The  principles  of  the  counterbalancing  substances  are 
found  in  animal  glands,  but  these  for  the  most  part  also  remain 
to  be  determined  with  any  degree  of  precision. 

Where  the  disturbance  is  of  thyroid  origin,  methods  have 
been  fairly  well  worked  out,  and  there  has  been  some  success 
with  suprarenal  unbalances,  but  the  pituitary  and  other  glands 
have  not  yet  revealed  their  secrets. 


266  THE    ENDOCRINES 

Based  on  the  rapid  strides  made  since  this  particular  study 
was  begun  in  1912,  there  seems  to  be  no  limit  to  the  possibilities 
which  the  research  of  the  next  few  years  may  open.  The  key 
may  safely  be  said  to  have  been  found  and  the  lock  turned;  it 
remains  to  discover  what  lies  beyond  in  definite  methods  of 
diagnosis  and  treatment. 

Means  for  this  research,  so  vital  for  the  protection  and 
welfare  of  every  home,  are  not  now  at  hand.  Such  institutions 
as  we  have  were  designed  and  established  for  the  most  part 
only  for  segregation  or  punishment.  There  is  no  provision  for 
the  necessary  constant  observation  and  treatment. 

It  is  foolish  to  build  institutions  for  detaining  defectives 
for  long  periods  as  a  punishment  for  a  condition  for  which 
they  are  not  responsible,  and  then  discharge  them  without 
doing  anything  to  remove  the  cause  of  their  trouble.  Every 
person  handled  in  this  manner  is  not  only  an  expense  to  the 
State,  but  he  is  made  a  potential  menace  to  the  State.  His 
emotional  instability  lays  him  wide  open  to  all  sorts  of  con- 
cepts and  impulses  from  intellectual  criminals. 

The  attitude  of  the  public  and  of  the  State  toward  the 
social  problem  must  be  changed  if  conditions  are  to  be  im- 
proved. Hospitals  must  be  substituted  for  prisons  and  treat- 
ment for  punishment,  so  far  as  defectives  are  concerned. 
(Schlapp.) 


CHAPTER    XV 
NEUROSES  AND  PSYCHOSES 

All  changes,  from  mild  depression  or  exaltation  to  melan- 
cholia and  dementia,  may  be  seen  in  dysthyroidism,  but  the 
milder  forms  resembling  "neurasthenia"  are  the  most  frequent; 
disorders  of  sleep,  up  to  severe  insomnia,  are  present  in  almost 
half  of  the  cases  of  hyperthyroidism. 

Neurotic  symptoms  are  often  suggestive  of  myxedema  and 
curable  by  thyroid.  In  myxedema,  patients  are  depressed  al- 
most to  the  verge  of  melancholy  without  the  self-accusation  and 
despair  of  true  melancholia.  They  are  sluggish  in  their 
thought,  unable  to  remember  recent  events,  indifferent  to  their 
surroundings,  without  interest  in  personal  and  family  affairs. 
They  take  an  unfavorable  view  of  their  own  condition,  their 
will  power  is  impaired.  There  is  a  mental  inertia,  they  are 
inclined  to  be  sleepy,  and  often  sleep  heavily  both  day  and 
night  and  awake  without  any  sense  of  refreshment   (Starr). 

Physically  there  is  a  dryness  of  the  skin  and  hair;  the 
skin  does  not  perspire,  it  becomes  pigmented ;  the  hair  falls  out 
or  becomes  gray.  The  surface  of  the  body  is  cold,  the  hands 
and  feet  are  always  cold.  Appetite  and  digestion  are  impaired. 
There  is  an  interference  with  the  calcium  metabolism.  There 
is  a  progressive  gain  in  weight.  There  may  be  constant  pain 
in  the  muscles  and  bones.  Levi,  of  Paris,  says  that  in  many 
cases  of  chronic  rheumatism  thyroid  treatment  is  the  best. 
When  nervous  or  "neurasthenic"  patients  complain  of  such 
symptoms,  one  grain  of  thyroid  twice  a  day,  added  to  the  other 
treatment,  is  of  value.  In  ten  days  the  effect  should  be  evident 
in  less  dryness  of  the  skin,  in  relief  from  the  sensation  of  cold, 
and  in  the  decided  improvement  in  mental  activity. 

Mental  sluggishness  in  young  girls,  with  symptoms  re- 
sembling dementia  praecox,  and  considered  as  cases  of  weak- 
mindedness,  may  obtain  mental  activity  by  taking  thyroid.  The 
symptoms  are  not  enough  to  warrant  the  diagnosis  of  myxe- 

267 


268  THE    ENDOCRINES 

dema,  but  the  dry,  scaly  skin,  dryness  of  the  hair,  and  coldness 
of  the  body  suggests  the  use  of  thyroid  extract.     (Starr.) 

Neurotic  Symptoms  of  Hyperthyroidism. — There  is 
nervous  excitability,  very  active  mentality,  tremor,  muscular 
irritability,  and  quickness  of  thought.  Excessive  function  of 
the  thyroid,  not  sufficient  to  produce  exophthalmos  or  goiter, 
or  a  very  rapid  pulse,  may  produce  symptoms  of  a  nervous 
character  simulating  "neurasthenia." 

Certain  people  are  restless  and  cannot  keep  quiet,  find 
it  impossible  to  lie  down  or  rest,  are  unable  to  keep  their 
minds  on  any  one  subject  for  any  length  of  time.  They  realize 
that  the  train  of  thought  is  unusual,  and  they  fear  insanity. 
They  have  a  sense  of  heat  in  the  body,  a  desire  for  cool  air 
and  fresh  air,  a  burning  sensation,  which  leads  them  to  sleep 
with  light  bed-clothing,  and  very  frequently  leads  to  perspira- 
tion; the  desire  for  cool  air  prevents  them  from  going  to  the 
theatre  or  church  or  remaining  in  hot  rooms. 

The  skin  is  shiny  and  moist,  the  hair  is  moist  and  glossy, 
and  the  patients  are  usually  thin.  There  is  tremor  about  the 
hands  and  exaggerated  knee-jerks,  patients  are  subject  to 
diarrhea,  menstruation  is  altered,  they  sleep  badly,  complain 
of  sudden  flashes  of  heat,  pulse  between  80  and  90. 

When  these  conditions  are  present  in  a  case  of  "neuras- 
thenia" the  thyroid  gland  is  probably  over-acting  (Starr). 

Hypopituitarism — "Drowsiness,  torpidity,  occurs  with 
hypopituitarism.  Many  of  the  patients  show  an  inclination  to 
dose  throughout  the  twenty-four  hours ;  in  others,  the  somno- 
lent period  occurs  in  more  or  less  definite  cycles,  with  inter- 
vening days  of  normal  response.  Glandular  therapy  improves 
the  mental  activity  and  lessens  the  drowsiness.  Sleeplessness 
would  be  expected  to  accompany  hypersecretion,  but  this  is 
rarely  noted"  (Gushing).  I  find  sleeplessness  and  headaches 
generally  associated  with  overactivity  of  the  posterior  lobe.  I 
find  overactivity  of  the  posterior  lobe,  if  associated  with  thyroid 
minus,  the  most  frequent  cause  of  high  blood-pressure  (Band- 
ler). 

Anesthesia,  or  insensitiveness  to  pain,  and  obstipation  are 


NEUROSES     AND     PSYCHOSES  269 

associated  with  hypopituitarism.  Psychic  disturbances — some 
are  due  to  excess  or  perversion  of  secretion,  others  to  insuffi- 
ciency. 

With  hypopituitarism  there  are  gradations  of  disturbance 
from  mild  psychoses  to  extreme  mental  derangement.  There 
is  inability  to  concentrate;  there  is  impairment  of  memory. 
Former  powers  of  mental  activity  may  be  restored  with  the 
readjustment  of  a  physiologic  balance  through  glandular  ad- 
ministration. In  most  cases  of  hypopituitarism  sufficient  to 
cause  adiposity,  deviations  from  the  normal  intellectual  level 
may  be  expected.  There  may  also  be  drowsiness.  Psychic 
disturbances  of  varying  degree  are  common."    (Gushing.) 

Dercum's  disease  includes  psychic  derangement. 

]\Iany  patients  with  hypopituitarism  have  shown  epilepti- 
form tendencies. 

"As  the  posterior  lobe  secretion  normally  enters  the  cere- 
brosp-inal  fluid,  and  thus  comes  in  contact  zi'ith  the  solution 
z^'hich  bathes  the  cortex,  if  is  possible  tlmt  its  diminution  in 
hypophyseal  disease  may  unfaz'orably  affect  the  activity  of  the 
cortical  cells."    (Gushing.) 

There  are  mental  changes,  such  as  lack  of  ambition,  in- 
difference to  matters  of  importance,  inability  to  do  ordinary 
work,  and  a  state  of  mind  such  as  seen  with  chronic  opium 
habit.  The  extreme  forms  are  easily  recognized.  In  so- 
called  "neurasthenics"  many  minor  conditions  are  probably 
due  to  disturbances  of  this  gland.  There  is  also  a  type  of  neu- 
rasthenic who  is  fat,  gaining  in  weight,  has  a  lack  of  ambition, 
craving  for  sweets,  and  in  all  probability  some  of  the  nervous 
manifestations  are  due  to  the  hypophysis.  In  two  or  three  such 
cases  of  marked  headache,  the  use  of  pituitary  extract  has 
caused  relief  and  has  improved  many  of  the  nervous  symptoms. 
These  cases  may  also  be  improved  by  thyroid  extract,  which  acts 
very  much  like  hypophysis.  Starr  gives  one  or  two  grains  a  day 
for  ten  days,  then  an  intermission  of  five  days,  and  then  again. 

Hyperpituitarism — "\\'ith  hyperpituitarism  tempera- 
mental changes  are  often  apparent  with  zvakc fulness,  lack  of 
concentration,    indecisiveness,    irritability,    distrust,    in   other 


270  THE    ENDOCRINES 

words,  psychasthenic  states,  which  are  not  unlike  those  with 
which  we  are  familiar,  in  moderate  degrees  of  dysthyroidism. 
When  hyperpituitarism  dates  from  early  life,  the  individual 
is  usually  deficient  in  educational  training  from  the  outset. 
(  Gushing. ) 

Neuroses  Connected  with  Ovarian  Atrophy. — ^Men- 
tal irritability  is  the  most  distressing  symptom;  the  sense  of 
apprehension,  inability  to  control  the  temper,  restlessness,  states 
of  depression,  defects  of  judgment  and  memory,  lack  of  self- 
control,  are  frequent  symptoms;  intense  headache,  pain  in  the 
back  of  the  head  and  neck,  sudden  flushes,  sensations  of  pres- 
sure in  the  head,  irregular  digestion,  irritability  of  the  bladder, 
pains  in  the  muscles.  The  majority  of  these  symptoms  are 
due  to  overactivity  of  the  posterior  pituitary  which  overactivity 
occurs  then  after  cessation  of  ovarian  function. 

These  symptoms  seem  to  be  periodically  increased  after 
menopause,  at  a  time  coincident  with  what  should  be  the  nor- 
mal period,  but  are  more  or  less  present  for  two  or  more  years 
after  suppression  of  the  function  of  the  ovaries.  Many  of 
the  symptoms  appearing  at  the  menopause  are  suggestive  of 
the  hypersecretion  of  the  thyroid,  as  they  are  similar  to  symp- 
toms occurring  in  Basedow's  disease,  but  they  are  not  wholly 
hypersecretion  of  the  thyroid.  Most  of  the  symptoms  are  due 
to  overactivity  of  the  adrenal  medulla  and  especially  of  the 
posterior  pituitary.  Corpus  luteum  makes  the  hyperthyroid 
cases  worse.  It  may  help  the  hyperpituitary  cases.  Placental 
extract  helps  the  latter,  often  quite  specifically. 

The  relation  of  thyroid  and  ovaries  is  shown  by  the  swell- 
ing of  the  thyroid  during  the  first  weeks  of  married  life.  When 
the  ovaries  cease  to  perform  their  functions,  they  may  be  ( 1 )  a 
hypersecretion  of  the  thyroid  leading  to  the  sense  of  deep 
flushes,  rapid  pulse,  and  mental  irritability;  or  there  may  be 
(2)  cessation  of  the  thyroid,  leading  to  an  accumulation  of  fat, 
a  sluggish  state  of  metabolism,  and  depression  and  partial 
dementia;  the  first  form  is  treated  by  the  use  of  ovarian  ex- 
tract, ovarian  residue,  suprarenal  extract,  adrenal  cortex  for 
weeks,  the  latter  by  the  use  of  thyroid  for  a  long  period. 


CHAPTER   XVI 
PHOBIAS 

Nothing  can  contribute  more  to  the  valuable  study  of 
human  nature,  to  a  proper  understanding  of  psychology,  and 
to  an  explanation  of  mental  states  and  psychoses  than  adequate 
proof  of  the  fact  that  the  instincts  and  the  emotions  have  a 
neuro  physical  basis,  and  are  not  produced  solely  and  entirely 
by  cerebral  activity.  If  the  instincts  of  flight,  pugnacity,  gre- 
gariousness,  repulsion,  suggestibility,  contra-suggestion,  etc., 
are  each  in  their  turn  an  evidence  of  and  the  result  of  definite 
and  specific  endocrine  activity,  much  that  seems  wonderful  will 
be  simple. 

I  might  begin  now  with  the  question,  ''Why  is  it  that  a 
red  rag  irritates  a  bull  ?"  The  retina  in  its  pigmentation,  and 
because  of  its  pigment,  must  be  in  close  association  with  the 
suprarenals.  Referring  now  to  the  adrenal  connection,  there 
are  certain  retinal  cells  and  fibres  which  are  connected  through 
the  autonomic  system  with  the  adrenal  medulla;  there  are 
certain  cells  connected  through  the  same  system  with  the  adre- 
nal cortex,  and,  therefore,  as  the  retina  in  different  animals, 
races  and  in  different  individuals  differs  in  its  "structure  and 
sensitiveness,  so  in  the  bull  the  connection  with  the  adrenals, 
especially  the  cortex,  is  such  that  red,  as  a  color,  immediately 
stimulates  and  rouses  it  and  associated  glands  with  the  resulting 
production  of  the  instinct  of  pugnacity  and  the  emotion  of 
anger. 

The  possibilities  of  such  interpretation  lead  us  to  readily 
understand  why  black  and  darkness  depress  and  frighten,  since 
the  connection  with  and  influence  on  the  adrenal  medulla  is  a 
neuro  physical  one. 

The  negro  race  with  its  fondness  for  bright  colors  Illus- 
trates the  physical  basis  just  mentioned.  As  the  skin  pigment 
calls  our  attention  to  such  a  possibility,  it  can  be  readily  appre- 
ciated that  the  retinal  composition  and  sensitiveness  differs 
from  that  of  the  white  races,  and  for  that  reason  the  retina  is 

271 


272  THE    ENDOCRINES 

extremely  sensitive  to  bright  colors.  It  is  not  enough  to  say 
that  this  race,  because  of  its  lack  of  education  and  training,  is, 
for  that  reason  only,  naturally  sensitive  to  certain  bright  pig- 
ments. The  negro  race  is  very  subject  to  fibroids  or  fibromyo- 
mata.  This  points  to  excessive  activity  in  them  of  the  posterior 
pituitary  lobe  since  this  gland  with  or  without  the  aid  of  the 
anterior  pituitary  is  responsible  for  these  uterine  tumors.  This 
excessive  action  of  the  posterior  pituitary  in  the  negro  race 
plus  the  adrenal  makeup  would  readily  account  for  their  emo- 
tional character,  etc.  If  to  this  be  added  a  gonadal  relation- 
ship different  from  that  in  white  people,  the  genital  differences 
are  to  be  readily  understood. 

The  same  difference  in  sensitiveness  and  attraction  holds 
true  with  the  impressions  made  through  the  ear  and  the  sense 
of  hearing,  and  likewise  holds  true  of  the  other  senses.  So 
the  music  of  the  negro  differs  from  that  of  the  whites,  and 
so  the  music  of  various  races  shows  equally  great  differences. 
Music,  characteristic  of  the  different  races,  has  therefore  not 
only  a  psychic  but  a  physical  basis  for  its  character  and  type 
since  both  physical  and  psychic  states  are  due  to  endocrines. 

And  so  races  differ  primarily  in  color,  facial  character, 
body  form,  mental  attitude,  suggestibility,  pugnacity,  educa- 
tion, tastes,  customs,  wisdom,  energy,  etc.,  along  the  lines  of 
endocrine  co-relation  and  inter-relation,  and  numerous  differ- 
ences in  skin  pigment,  in  instincts,  emotions,  mental  ability, 
pugnacity,  fear,  gregarious  instinct  and  other  instincts,  emo- 
tions and  characteristics  .are  to  be  found  among  the  individ- 
uals of  each  race.  There  is  not  an  instinct  or  an  emotion, 
whatever  divisions  or  classifications  a  psychologist  may  make, 
that  cannot  be  readily  accounted  for  on  an  endocrine  basis,  and 
psychoses  are  simply  exaggerations  of  an  abnormal  character 
of  any  one,  two  or  more  of  the  simple  and  ordinary  instincts 
and  emotions  with  which  the  human  being  and  especially  the 
physician  has  to  deal. 

People  who  are  off  the  normal  line  as  to  music  (ear), 
as  to  colors  (eye),  and  to  combination  of  colors  (as  in  certain 
schools),  are  very  apt  to  be  off  the  normal  in  their  instincts 


PHOBIAS  273 

and  emotions  since  the  physical  basis  for  the  one  as  it  runs 
back  to  the  endocrines  presupposes  a  different  endocrine  rela- 
tion at  the  bottom  of  the  instincts  and  emotions.  This  off 
from  the  normal  as  to  tastes,  dependent  on  any  of  the  senses, 
presupposes  a  like  deviation  in  instincts,  emotions  and  psychic 
reaction  and  behavior. 

Life  is  a  struggle  in  many  ways.  An  important  contest 
is  that  between  the  endocrines,  which  are  the  main  factors 
conferring  immunity,  on  the  one  hand,  and  bacterial  infections 
and  physiological  processes  on  the  other.  So  results  the  sur- 
vival of  the  fittest.  In  addition  to  bacteria  the  storm,  the 
stress  and  the  accidents  of  environment  and  of  life  are  playing 
an  all  important  part. 

I  wish  to  attract  attention  to  the  thyroid  gland,  to  the 
adrenals,  to  the  pituitary,  and  to  that  structure  in  the  ovary 
known  as  the  corpus  luteum.  For  it  is  the  thyroid,  the  adre- 
nals and  the  posterior  pituitary  which  are  the  end  organs  most 
closely  related  to  fears,  anxieties  and  phobias.  But  in  the 
absence  of  infections,  the  little  devil  physically  responsible  as 
a  primary  factor  is  the  corpus  luteum,  responsible  in  the  sense 
that  it  makes  women  and  the  female  more  liable  to  fears.  I 
have  advisedly  said  physically  responsible  and  I  now  come  to 
the  question  of  psychic  responsibility. 

Impressions  made  during  the  early  years  of  childhood  are 
the  most  lasting  as  concerns  the  instincts  and  the  emotions 
even  though  not  remembered.  Stimuli  through  any  of  the 
senses  without  consciousness  but  especially  when  associated 
with  consciousness  follow  definite  neuro  endocrine  paths  and 
result  in  emotions  and  the  typical  behavior  associated  with 
these  emotions.  Of  all  the  elements  through  life  which  pro- 
duce injurious  effects  and  lasting  harm,  fear  stands  at  the 
head. 

Some  children  are  not  easily  frightened;  others  are  more 
readily  frightened,  and  still  others  are  of  an  extremely  fearful 
or  fearsome  nature,  and  to  call  these  neurotic  or  psychopathic, 
and  to  say  that  they  have  inherited  these  conditions  may  be 
only  too  true,  but  it  explains  nothing  which  the  parents  can 

i8 


274  THE    ENDOCRINES 

understand,  and  hope  to  correct,  nor  do  these  terms  imply  in 
the  least  that  the  physician  recognizes  that  there  is  something 
wrong  which  may  be  corrected.  Parents  must  and  should  do 
everything  with  children  to  avoid  inculcating  fear,  and  should 
remove  any  element  of  fear  as  much  as  possible  from  the  mind 
and  consciousness  of  the  child.  At  a  later  age  fears,  though* 
not  remembered  as  having  been  experienced  earlier,  may  and 
do  persist  as  sensitive  paths  and  so  continue  throughout  the 
whole  life  of  the  affected  individual. 

Little  Red  Riding  Hood,  Grimm's  Fairy  Tales  and  stories 
relating  to  death,  to  fearsome  things,  etc.,  should  be  entirely 
abolished  from  the  life  of  the  child.  Threats,  punishments, 
etc.,  which  rouse  fear  are  a  most  criminal  part  of  the  so-called 
disciplinary  methods  introduced  into  the  life  of  the  child. 
Some  children  are  not  readily  frightened,  others  very  easily. 
What  do  we  know  of  the  dreams  of  the  child,  filled  often 
enough  with  fear  and  terror,  thus  reproducing,  during  what 
should  be  restful  sleep,  the  ofttime  terrible  and  horrible  im- 
prints made  upon  the  mind  and  psyche. 

In  physical  fear,  the  adrenals  are  the  endocrines  especially 
associated  with  this  emotion.  The  less  is  the  response  of  the 
adrenal  cortex,  and  the  more  sensitive  is  the  adrenal  medulla, 
the  more  likely  is  the  child  to  experience  fear.  The  more  active 
is  the  thyroid  and  the  more  sensitive  its  reaction,  the  more  it 
enhances  the  tendency  to  the  emotion  of  fear  and  the  instinct  of 
flight.  When  a  child  wakes  in  fear  or  terror,  or  without  this 
evidence  wants  to  go  into  the  bed  of  its  mother  or  its  nurse, 
that  child  is  anxious  and  frightened.  When  a  child,  on  retir- 
ing, makes  excuses  to  call  its  mother  or  nurse  to  the  bedside, 
wants  a  light  in  the  room,  or  a  light  in  the  hall,  that  child  is 
frightened.  When  I  realize  how  little  understanding  there  is 
of  this  fact  among  parents  and  physicians,  I,  in  my  turn, 
shudder  at  the  injustice  done  to  myriads  of  children  by  the 
different  disciplinary  methods  of  "Teaching  that  child  to  be- 
have." 

I  marvel  at  our  slow  pace  in  recognizing  the  importance 
of  all  the  endocrines  from  the  day  of  birth  on.    We  know  how 


PHOBIAS  275 

necessary  the  anterior  pituitary  and  the  thyroid  are  to  mental 
and  physical  development.  We  are  beginning  to  realize  the 
value  of  the  adrenal  cortex;  we  are  beginning  to  realize  that 
the  thyroid  has  two  totally  distinct  secretory  structures,  but 
where  do  we  stand  on  the  question  of  the  ovary?  The  inter- 
stitial ovary  and  the  glandular  are  functionating  all  the  time 
and  are  most  important  to  the  physical,  mental  and  psychic 
welfare  of  the  child  and  of  the  adult.  If  attention  were  paid 
to  what  I  am  now  saying,  we  would  find  in  thousands  of  little 
girls  a  cyclic  premenstrual  wave  noticed  in  the  sphere  of 
behavior  and  psychic  reactions  where  now  no  attention  is  paid 
to  such  a  possibility  since  little  girls  do  not  menstruate.  But 
even  when  they  do  begin  to  menstruate,  and  at  the  stage  of 
puberty  do  evidence  symptoms  pointing  to  hyperthyroidism 
and  other  symptoms  resembling  these,  but  due  to  hyperactivity 
of  the  adrenal  medulla,  even  then  very  little  attention  is  paid 
to  the  premenstrual  constitutional  and  psychic  phenomena. 

The  two  secretions  of  the  ovary  and  the  two  secretions 
of  the  thyroid  stimulate  each  other  but  are  at  the  same  time 
antagonistic.  This  relation  of  stimulation  or  production  of 
normal  balance  between  any  two  glands  or  between  the  two 
parts  of  each  gland  is  essential  to  the  normal  action  of  those 
glands  or  parts  of  each  gland  on  the  body,  visceral  functions 
and  psyche  of  any  individual.  For  perfect  health  there  must 
be  a  normal  balance  between  the  anterior  and  posterior  pitui- 
tary, between  the  interstitial  and  glandular  portion  of  the  thy- 
roid, between  the  adrenal  cortex  and  the  adrenal  medulla,  be- 
tween the  interstitial  ovary  and  the  glandular  ovary^  between 
the  interstitial  and  glandular  pancreas,  between  the  interstitial 
and  glandular  kidney,  etc.  For  perfect  health  there  must  be 
a  normal  balance  between  these  glands  and  the  parathyroid 
and  the  thymus  and  the  pancreas,  and  pineal,  etc.  In  my  ex- 
perience the  importance  of  the  parathyroids  has  been  grossly 
underestimated,  and  this  gland  and  the  pineal  are  receiving 
from  me,  as  the  other  glands  have  long  received  from  me,  more 
and  more  attention  from  the  therapeutic  standpoint. 


276  THE    ENDOCRINES 

But  the  little  devil  in  this  chain  is  the  corpus  luteum  of 
the  glandular  ovary.  The  only  secretions  which  the  female  has, 
which  the  male  has  not,  are  the  corpus  lutem,  the  mammary  and 
the  placenta.  This  latter  gland  extract  has  been  used  therapeu- 
tically by  me  in  several  hundred  cases  so  that  I  now  can  affirm 
that  it  is  one  of  the  most  important  additions  to  our  therapy, 
and  it  seems  to  be  an  antagonist  able  to  put  many  of  the  en- 
docrines,  especially  the  posterior  pituitary,  to  sleep.  But  thy- 
roid diseases  and  overactivity  of  the  adrenal  medulla  are  pecu- 
liar to  women,  and  we  know  the  thyroid  diseases  are  ten  times 
as  frequent  in  women  as  in  men.  Thyroid  affections,  especially 
hyperthyroidism,  vary  in  severity  and  symptoms  according  to 
the  degree  to  which  other  glands,  especially  the  adrenals,  are 
involved.  Thyroid  diseases  varj-  likewise  according  to  the 
degree  to  which  the  interstitial  or  the  gland  element  of  the 
thyroid  are  involved.  One  reason  why  women  are  so  liable 
to  thyroid  affections  is  that  they  produce  and  retain  within 
their  ovaries  persistent  corpora  lutea.  For  years  I  have  lec- 
tured, and  proven  by  therapy,  that  the  corpus  luteum  is  a  totally 
different  secretion  from  that  of  the  ovary  itself,  and  that  the 
indications  for  its  administration  are  directly  the  opposite  of 
that  for  administration  of  ovarian  extract  and  of  ovarian  resi- 
due. Hence,  my  therapeutic  results  of  the  last  twenty  years 
can  be  readily  explained. 

In  1906  I  published  in  the  American  Journal  of  Obstetrics 
an  article  entitled  "Associated  Nervous  Conditions  in  Gynecol- 
ogy with  Especial  Reference  to  the  Climacterium  and  Allied 
States."  There  were  reported  twenty-eight  cases  of  hyper- 
thyroidism. These  were  made  worse  by  thyroid  extract  ad- 
ministered to  verify  diagnosis.  The  important  point  was  that 
ovarian  extract  whole  gland  was  the  specific  therapy.  In  sev- 
eral publications  I  pointed  out  that  persistent  corpora  lutea  in- 
hibited ovulation  and  were  the  responsible  factors  in  many 
cases  of  sterility;  that  many  of  these  cases  were  cured  by  the 
administration  of  ovarian  extract  with  small  doses  of  thyroid 
and  other  extracts,  while  others  conceived  only  after  surgical 
removal  of  the  retained  cysts  and  corpora  lutea. 


PHOBIAS  277 

I  have  prescribed  corpus  luteum  once  in  comparison  with 
ovarian  extract  with  or  without  ovarian  residue  fifty  times,  and 
now  many  who  have  prescribed  corpus  luteum  extract  as  a 
routine  are  at  last  seeing  the  light. 

The  glandular  ovary  and  the  corpus  luteum,  as  stated 
above,  is  the  only  secretion  which  can  by  any  possibility  be 
made  specifically  the  primary  responsible  factor  for  the  greater 
tendency  to  hyperthyroidism  in  women.  Since  we  know  that 
ovarian  extract  and  ovarian  residue  are  antagonistic  to  the 
corpus  luteum,  and  since  overactivity  of  the  adrenal  medulla 
is  often  an  accompaniment  of  hyperthyroidism,  we  may  the 
more  readily  understand  why  ovarian  extract  and  suprarenal 
extract,  which  contains  the  cortex,  are  of  such  undoubted 
value  in  certain  forms  of  hyperthyroidism.  Since  overactivity 
of  the  posterior  pituitary  is  likewise  present,  especially  in  the 
exophthalmic  cases,  the  value  of  placental  extract  may  likewise 
be  recognized. 

So  far  as  adrenalin  is  concerned,  I  long  ago  discontinued 
its  use  in  the  emergency  complications  occasionally  seen  in 
post-operative  cases,  feeling  that  it  often  did  harm  and  not 
good,  and  just  as  soon  as  an  extract  of  the  adrenal  cortex, 
which  at  present  is  found  in  suprarenal  extract,  is  in  our  hands, 
w^e  will  then  have  one  of  the  several  new  extracts  which  will 
save  life  and  tide  patients  over  the  critical  periods  in  the  in- 
fectious diseases,  and  in  post-operative  complications.  The 
anxious  facies  which  is  noted  in  pneumonia,  in  infectious  dis- 
eases and  in  peritonitis  has  a  meaning  of  great  significance. 
It  points  distinctly  to  the  adrenals. 

Let  me  say  that  an  actual  or  relative  inadequancy  of 
the  adrenals  or  of  the  adrenal  cortex  may  be  congenital  or  ac- 
quired. It  may  result  through  the  infectious  diseases  of  child- 
hood, particularly  through  influenza ;  it  may  be  caused  by 
pregnancy  and  labor,  very  frequently  by  lactation,  etc.,  but  I 
believe  that  psychic  experiences,  mental  shocks,  etc.,  are  just 
as  able  to  injure  a  sensitive  endocrine  or  part  of  an  endocrine 
or  to  stimulate  an  endocrine,  or  part  of  an  endocrine,  as  are  the 
infectious  diseases  or  normal  processes.    On  the  other  hand  in- 


278  THE    ENDOCRINES 

fluenza  or  any  infectious  disease,  or  a  physiological  function 
or  a  physiological  process  may  arouse  or  stimulate  a  gland  or 
glands  or  part  of  a  gland  to  increased  activity,  so  that  even 
after  an  influenza  or  an  infectious  disease  and  certainly  after 
pregnancy  some  patients  are  in  better  health  than  before. 

It  must  be  remembered  that  the  addition  of  other  extracts 
has  a  powerful  influence  in  aiding  the  correction  of  the  states 
of  terror,  fear  and  anxiety.     (Testicular  extract,  ant.  pit.,  etc). 

The  pituitary  gland  is  closely  related  to  fears,  phobias, 
states  of  anxiety,  suspicion,  etc.  A  lack  of  balance  between 
the  anterior  and  posterior  lobes  with  the  associated  lack  of 
stimulation  or  overstimulation  of  the  brain  cells  is  an  im- 
portant factor.  The  posterior  pituitary  is  associated  with  con- 
trol over  kidney  function.  If  underactive,  urinary  excretion 
may  be  increased  (diabetes  insipidus).  If  overactive,  urinary 
excretion  may  be  diminished  or  on  the  other  hand  increased. 
There  are  with  posterior  pituitary  changes  the  same  types  of 
interference  with  osmosis  in  the  cerebro-spinal  fluid.  Over- 
activity of  the  posterior  pituitary  is  thus  responsible  for  hyper- 
tension of  the  cerebro-spinal  fluid,  especially  with  thyroid 
minus,  but  not  with  thyroid  minus  only.  Then  come  the  typical 
occipital  headaches  running  behind  the  ears,  down  the  neck, 
spine  and  legs,  to  be  viewed  as  an  evidence  of  posterior  pitui- 
tary plus  with  increased  pressure  in  the  cerebro-spinal  canal. 
This  state  is  observed  especially  in  the  preeclamptic  and  eclamp- 
tic patients.  This  posterior  pituitary  involvement  occurs  in 
association  with  kidney  lesions  after  infections,  especially  in- 
fluenza. The  kidney  epithelium  is  the  more  vulnerable,  the 
more  the  thyroid  is  injured  and  its  secretory  activity  is  dimin- 
ished. Even  with  thyroid  plus,  the  posterior  pituitary  is  often 
overactive  and  then  the  high  blood  pressure  in  the  general 
circulation  is  not  noted.  My  observations  and  therapy  show 
that  posterior  pituitary  plus  is  a  frequent  accompaniment  of 
the  severe  forms  of  hyperthyroidism,  of  exophthalmos,  and  of 
exophthalmic  goitre.  Posterior  pituitary  is  a  frequent  cause 
of  anxieties,  fears,  phobias,  suspicions,  etc.  It  is  not  always 
easy  to  determine  whether  it  is  overacting  or  underacting, 


PHOBIAS  279 

for  the  associated  activities  of  the  thyroid,  adrenal  medulla, 
adrenal  cortex,  etc.,  have  to  be  taken  into  consideration.  Pla- 
cental extract  and  thyroid  antagonize  the  posterior  pituitary. 
The  thyroid  is  the  great  regulator  of  posterior  pituitary  activ- 
ity. Placental  extact  likewise  by  its  action  on  this  lobe  and 
by  the  effect  it  has  on  the  osmosis  in  the  cerebro-spinal  canal 
is  a  therapeutic  agent  of  the  greatest  value.  Pituitary  is  re- 
sponsible for  psychic  fears  as  distinguished  from  physical  fear, 
if  such  a  distinction  can  be  made. 


THE  AUTONOMIC  NERVOUS  SYSTEM 

CHAPTER  XVn 

The  investigations  of  Eppinger  and  Hess  concerning  the 
vegetative  nervous  system  whereby  the  latter  was  divided, 
broadly  speaking,  into  the  Sympathetic  on  the  one  hand,  and 
the  Vagus  on  the  other,  attracted  attention  to  the  importance 
of  this  system. 

The  Sympathetic  was  said  to  dilate  the  pupil,  protrude 
the  eye,  accelerate  the  heart,  inhibit  peristalsis,  relax  the 
spincters,  cause  glycosuria  and  polyuria,  etc. 

The  Vagus  was  said  to  contract  the  pupil,  slow  the  heart, 
increase  peristalsis,  stimulate  the  gastric  juice,  etc. 

Adrenalin  stimulates  the  Sympathetic;  Pilocarpine  stimu- 
lates the  Vagus;  Atropin  paralyzes  the  Vagus. 

.  Vagotonia,  relative  or  actual  predominance  of  the  Vagus 
system,  was  said,  among  other  things,  to  be  responsible  for 
asthma,  bradycardia,  angina  pectoris,  etc. 

The  Suprarenal  Cortex  is  probably  a  stimulator  of  the 
Vagus. 

Sympaticotonia  was  said  to  be  responsible  for  dermo- 
graphism, embarrassment,  hyperidrosis,  diarrhea,  tachycardia, 
congestion  of  the  head,  etc. 

In  sleep,  the  Sympathetic  is  supposed  to  be  at  rest,  hence 
the  relative  predominance  of  the  Vagus  with  the  narrow 
pupils,  slow  pulse,  perspiration,  etc.  For  that  reason,  asthma, 
colic  and  labor  pains  develop  so  often  when  the  Sympathetic  is 
at  rest. 

Pigmentations  were  credited  to  the  Vagus  Nervous  Sys- 
tem and  are  observed  in  Addison's  Disease  and  Graves'  Dis- 
ease. Likewise  patches  of  gray  hair  on  one  side  associated 
with  migraine  and  hemicrania. 

Anaphylaxis  was  credited  to  Vagus  stimulation  and  is 
observed  often  in  the  young  in  the  form  of  asthma,  laryngeal 
spasm,  status  lymphaticus,  etc. 

280 


THE     AUTONOMIC     NERVOUS     SYSTEM  281 

The  vegetative  nervous  system  is  a  system  which  possesses 
ganglia  and  the  structures  it  innervates  are  not  subject  to 
voluntary  control.  There  are  centers  in  the  fourth  ventricle, 
in  the  subthalamic  region,  in  the  mesencephalon,  passing  to 
the  chromaffin  system,  to  the  thyroid  and  probably  to  other 
endocrines.  This  system  and  its  associated  endocrines  are 
readily  influenced  by  psychic  factors.  Though  formerly  the 
system  has  been  broadly  divided  into  the  Vagus  and  the  Sym- 
pathetic, the  following  arrangement  is  anatomically  more  ac- 
curate. 

Cannon  in  his  wonderful  work  on  the  adrenals  and 
adrenal  extract  gives  what  is  perhaps  the  best  and  most  scien- 
tific resume  of  this  system,  as  follows  : 

The  vegetative  nerv^ous  system  is  better  spoken  of  as  the 
"autonomic,"  which  name  is  perhaps  the  wiser  one  to  use. 

Autonomic  nerA'ous  system  (Langley)  indicates  that  the 
structures  which  this  system  supplies  are  not  subject  to  volun- 
tary control.  These  structures  are  readily  influenced  by  pain 
and  emotional  excitement. 

There  are  three  divisions:  (1)  cranial;  (2)  thoracico- 
lumbar;  (3)  sacral.  The  second,  or  thoracico-lumbar,  is  the 
sympathetic  system. 

The  neurone  relations  in  the  sympathetic  division  seem 
devised  for  widespread  diffusion  of  nervous  impulses. 

The  fibres  of  the  "sympathetic"  are  widely  distributed 
throughout  the  body.     They 

(1)  Dilate  the  pupils. 

(2)  Stimulate  the  heart, — cause  it  to  beat  rapidly  when 

stimulated. 

(3)  Carry  impulses  to  arteries  and  arterioles  of  skin, 

abdominal  viscera,  keeping  the  smooth  muscle  of 
vessel  walls  in  state  of  slight  contraction  or  tone, 
preserving  or  raising  (in  times  of  special  dis- 
charge of  impulses)  the  arterial  pressure. 

(4)  Distributed  to  smooth  muscle  attached  to  the  hairs, 

and  when  they  cause  this  muscle  to  contract  the 
hairs  are  erected. 


282  THE    ENDOCRINES 

(5)  They  go  to  the  sweat  glands,  causing  an  outpour 

of  sweat. 

(6)  They  pass  to  the  entire  length  of  the  gastro-intes- 

tinal  canal.  In  pain  and  emotional  states  diges- 
tive activitity  is  inhibited  by  impulses  carried  by 
the  splanchnic  branches  of  this  system, 

(7)  They    innervate    the    genito-urinary    tract,    causing 

contraction  of  the  smooth  muscle  of  the  internal 
genital  organs,  and,  usually,  relaxation  of  the 
bladder. 

(8)  They  effect  the  liver,  releasing  the  storage  of  ma- 

terial therein  in  time  of  need. 

Pain,  fear,  and  rage,  and  intense  excitement,  are  mani- 
fested in  the  activities  of  the  sympathetic  division.  When  in 
these  states  impulses  rush  out  over  the  neurones  of  this  division, 
they  produce  all  the  changes  typical  of  sympathetic  excitation, 
such  as  dilating  the  pupils,  inhibiting  digestion,  causing  pallor, 
accelerating  the  heart.  Sympathetic  fibres,  normally,  deliver 
impulses  which  cause  contraction  of  the  internal  genitals  and 
relaxation  of  the  stomach  and  intestines.     (Cannon.) 

The  cranial  and  sacral  divisions  of  the  autonomic  system 
have  a  restricted  distribution.  The  cranial  and  sacral  pre- 
ganglionic fibres  resemble  the  nerves  to  skeletal  muscles,  and 
their  arrangement  provides  similar  possibilities  of  specific  and 
separate  action  in  any  part  without  action  in  other  parts. 

The  cranial  autonomic,  represented  by  the  vagus  nerves 
is  concerned  in  the  psychic  secretion  of  gastric  juice.  The 
cranial  nerves  passing  to  the  salivary  glands  are  the  agents  for 
psychic  secretion  in  these  organs  and  cause  dilatation  of  ar- 
teries supplying  these  glands. 

Cranial  autonomic  fibres  contract  the  pupil  of  the  eye. 

Cranial  autonomic  fibres  slow  the  heart  rate.  The  third 
cranial  nerves  deliver  impulses  to  ganglia,  containing  neurones 
innervating  smooth  muscle  in  the  front  of  the  eye.  The  vagi, 
when  stimulated,  increase  the  tone  in  the  smooth  muscles  of 
the  alimentary  canal.  The  vagus  nerves  are  distributed  to  the 
lungs,  the  heart,  the  stomach,  the  small  intestines.     The  out- 


THE     AUTONOMIC     NERVOUS     SYSTEM  283 

lying  neurones  in  the  last  three  of  these  organs  lie  within  the 
organs  themselves.  The  vagus  nerve,  when  artificially  stimu- 
lated, has  a  primary  brief  inhibitory  effect  on  the  stomach  and 
small  intestine.  Its  main  function  is  to  produce  increased 
tone  and  contraction  in  these  organs.  Thus  the  vagus  has. 
here  a  double  action,     (Cannon.) 

The  cranial  and  sacral  divisions  supply  individual  ar- 
teries with  "dilator  nerves,"  The  cranial  and  sacral  divisions 
have  few  of  the  diffuse  connections  of  the  mid-division  or  sym- 
pathetic. 

The  vagi,  when  stimulated,  increase  the  tone  in  the 
smooth  muscles  of  the  alimentary  canal. 

The  sacral  autonomic  fibres  pass  out  to  ganglia  lying  in 
close  proximity  to  the  distal  colon,  the  bladder,  and  the  ex- 
ternal genitalia. 

Fibres  of  the  sacral  division  include  fibres  which 

(1)  Contract  the  rectum, 

(2)  Contract  the  distal  colon, 

(3)  Contract  the  bladder.     These  effects  result  reflexly 

from  stretching  of  the  tonically  contracted  viscera 
by  their  accumulating  contents. 

(4)  The   nervi   erigentes    which   bring   about   engorge- 

ment of  erectile  tissues  in  the  external  genitalia. 

The  sacral  nerves  of  the  autonomic  have  no  effect  on 
the  internal  genitalia  (Langley). 

"Distension  is  the  commonest  occasion  for  bringing  the 
sacral  division  into  activity.  Great  emotion  accompanied  by 
nervous  discharges,  by  way  of  the  sympathetic,  may  also  be 
accompanied  by  discharges  by  way  of  the  sacral  fibres.  Hence, 
involuntary  voiding  of  the  bladder  and  gut  at  times  of  violent 
mental  stress.  The  power  of  sights,  smells,  and  libidinous 
thoughts  to  disturb  the  regions  controlled  by  the  nervi  eri- 
gentes proves  that  this  part  of  the  autonomic  system  also  has 
its  peculiar  affective  states.  The  fact  that  one  part  of  the 
sacral  division,  that  is,  the  distribution  of  the  bladder,  may  be 
in  abeyance  while  another  part,  the  distribution  to  the  rectum 
is  -active,  illustrates  again  the  directive  discharge  of  impulses 


284  THE    ENDOCRINES 

which  are  characteristic  of  the  cranial  and  sacral  portions  of 
the  autonomic  system.  The  cranial  division  and  the  sacral 
division  are  engaged  in  the  performance  of  acts  leading  im- 
mediately to  greater  comfort."     (Cannon.) 

Many  of  the  viscera  are  innervated  both  by  the  cranial 
or  sacral  part  of  the  autonomic  and  by  the  sympathetic. 

Because  antagonisms  exist  between  the  sympathetic  and 
the  cranial  and  sacral  divisions,  affective  states  may  be  classi- 
fied according  to  their  expression  in  the  middle,  or  cranial,  or 
sacral  divisions,  and  these  states  would  be,  like  the  nerves, 
antagonistic  in  character. 

When  the  sympathetic  meets  either  the  cranial  or  the 
sacral  in  any  viscus,  their  effects  are  antagonistic.  The  cranial 
contracts  the  pupil;  the  sympathetic  dilates  it. 

The  cranial  slows  the  heart;  the  sympathetic  accelerates 
it. 

The  sacral  contracts  the  lower  part  of  the  large  intes- 
tines ;  the  sympathetic  relaxes  it. 

The  sacral  relaxes  the  exit  from  the  bladder;  the  sym- 
pathetic contracts  it. 

It  is  highly  probable  that  the  sympathetic  (because  ar- 
ranged for  diffuse  discharge)  is  likely  to  be  brought  into 
activity  as  a  whole,  whereas  the  sacral  and  cranial  divisions, 
arranged  for  particular  action  on  separate  organs,  may  operate 
in  parts.  The  impulses  of  the  sympathetic  neurones,  as  indi- 
cated by  their  dominance  over  the  digestive  process,  are  capable 
of  readily  overwhelming  the  conditions  established  by  neu- 
rones of  the  cranial  division  of  the  autonomic."     (Cannon.) 

Antagonism  between  emotions  expressed  in  the  sym- 
pathetic and  in  the  cranial  division  of  the  autonomic  system  is 
evidenced  as  follows :  Among  the  functions  of  the  cranial 
autonomic  are  the  relatively  mild  pleasures  of  sight,  and  taste, 
and  smell  of  food.  These  are  abolished  instantly  in  the  pres- 
ence of  emotions  which  activate  the  sympathetic.  The  secre- 
tion of  saliva,  gastric  juice,  pancreatic  juice  and  bile  is  stopped, 
and  the  motions  of  the  stomach  and  intestines  cease  at  once 


THE     AUTONOIMIC     NERVOUS     SYSTEM  285 

whenever  pain,  fear,  rage,  or  other  strong  excitement  is  present 
in  the  organism.     (Cannon.) 

Antagonism  between  emotions  expressed  in  the  sym- 
pathetic and  in  the  sacral  divisions  of  the  autonomic  system 
are  illustrated  as  follows :  The  nervi  erigentes  are  the  parts 
of  the  sacral  autonomic  in  which  the  peculiar  excitement  of  sex 
are  expressed.  These  nerves  are  opposed  by  branches  from 
the  sympathetic  division,  the  division  which  is  operated  char- 
acteristically in  the  major  emotions.  Prince  states,  "The 
suppression  of  the  sexual  instinct  by  conflict  is  one  of  the  most 
notorious  experiences  of  this  kind  in  every  day  life.  This 
instinct  cannot  be  excited  during  an  attack  of  fear  or  anger, 
and  even  during  moments  of  its  excitation  if  there  is  an  in- 
vasion of  another  strong  emotion  the  sexual  instinct  is  at  once 
repressed." 

The  vasa  deferentia  and  the  seminal  vesicles,  whose 
rhythmic  contractions  mark  the  acme  of  sexual  excitement  in 
the  male,  and  the  uterus,  whose  contractions  in  the  female  are 
probably  analogous,  are  supplied  by  the  lumbar  branches  of 
the  sympathetic.  These  branches  act  in  opposition  to  the  nervi 
erigentes  and  cause  contraction  of  the  vessels  to  the  external 
genitalia.  The  sexual  orgasm  involves  a  high  degree  of 
emotional  excitement,  but  it  can  be  rightly  considered  as  essen- 
tially a  reflex  mechanism ;  and,  again  in  this  instance,  disten- 
sion of  tubules,  vesicles  and  blood  vessels  can  be  found  at  the 
beginning  of  the  incident  and  relief  from  this  distension  in 
the  end. 

A\nien  the  acme  of  excitement  is  approaching  it  is  prob- 
able that  the  sympathetic  division  is  also  called  into  activity ; 
indeed  the  completion  of  the  process,  the  contractions  of  the 
seminal  vesicles  and  the  prostate  and  the  subsidence  of  en- 
gorged tissues,  all  innervated  by  sympathetic  filaments,  may  be 
due  to  the  overwhelming  of  sacral  by  sympathetic  nervous 
discharges.  As  soon  as  this  stage  is  reached,  the  original  feel- 
ing has  likewise  been  dissipated. 

"The  other  parts  of  the  sacral  division  which  supplv  the 
bladder  and  rectum  are  so  nearly  free  from  any  emotional 


286  THE    ENDOCRINES 

tone  in  their  normal  reflex  functioning  that  it  is  unnecessary 
to  consider  them  further  with  reference  to  emotional  an- 
tagonisms. Mild  affective  states,  such  as  worry  and  anxiety, 
can,  to  be  sure,  check  the  activity  of  the  colon  and  thus  cause 
constipation.  But  the  augmented  activity  of  these  parts  (con- 
traction of  the  bladder  and  rectum)  in  very  intense  periods  of 
emotional  stress,  when  the  sympathetic  division  is  strongly 
innervated,  presents  a  problem  of  some  difficulty.  Possibly  in 
such  conditions  the  orderliness  of  the  central  arrangements  is 
upset,  just  as  it  is  after  tetanus  toxin  or  strychine  poisoning, 
and  opposed  innervations  no  longer  discharge  reciprocally, 
but  simultaneously,  and  then  the  stronger  member  of  the  pair 
prevails.  Only  on  such  a  basis  at  present  can  I  offer  any 
explanation  for  the  activity  and  the  supremacy  of  the  sacral 
innervation  of  the  bladder  and  distal  colon,  when  the  sympa- 
thetic innervation  is  aroused,  as,  for  example,  in  great  fright." 
(Cannon.) 


CHAPTER    XVIII 

THE  BALANCE  BETWEEN  THE  ENDOCRINES  AND 
IN  EACH  INDIVIDUAL  ENDOCRINE 

The  cerebrum  is  affected  by  stimuli  through  the  senses 
(sight,  hearing,  smell,  taste,  touch,  pain  and  temperature,  etc.). 
The  autonomic  nervous  system  has  its  intimate  and  close  rela- 
tion with  the  cerebrum.  Stimuli  through  any  of  these  senses 
cause  reaction,  instinctive  action,  unconscious  and  conscious 
action.  Volition,  thought,  etc.,  are  functions  of  the  psyche  and 
the  mind.  As  a  result  of  certain  stimuli,  particularly  and 
definitely  such  as  are  associated  with  the  instincts  and  playing 
their  part  in  arousing  emotions,  there  is  response  on  the  part  of 
the  autonomic  nervous  system,  on  the  part  of  the  visceral  or- 
gans and  structures  with  which  they  are  connected,  and  a  re- 
sponse on  the  part  of  the  associated  endocrines.  The  autono- 
mic nervous  system,  in  its  relation  to  the  endocrines,  is  respon- 
sible for  and  responds  to  the  instincts  and  emotions.  The 
autonomic  nervous  system  may  be  divided  broadly  into  the 
vagus  and  the  sympathetic  which  produce  opposite  or  opposing 
actions  in  the  structures,  organs,  and  endocrine  glands  which 
both  innervate  and  supply.  A  relation  between  the  two  divi- 
sions of  the  autonomic  system  exists  and  is  supposed  to  pre- 
serve that  equilibrium  and  normal  balance  essential  to  normal 
action  and  normal  response  in  the  functions  of  the  organs 
which  they  supply.  An  excessive  control  above  the  normal 
balance  on  the  part  of  one  or  the  other,  or  variations  in  their 
normal  balance  differing  from  the  normal,  are  productive  of 
abnormal  action.  In  many  conditions  the  blame  may  be  laid 
on  overactivity  or  underactivity  of  one  or  other  of  these 
branches  of  the  autonomic  nervous  system  and  hence  in  the 
same  disease  there  are  minor  variations  from  the  typical  or 
supposedly  pathognomonic  signs. 

A  study  of  the  innervations  and  resulting  normal  func- 
tions regulated  by  the  autonomic  nervous  system  and  the  diag- 

287 


288  THE    ENDOCRINES 

nosis  of  altered  or  abnormal  function  of  any  of  the  structures 
so  innervated  constitutes  a  very  difficult  problem  and  from  the 
standpoint  of  therapy  leads  us  nowhere,  since  the  real  cause 
is  thereby  neither  divulged  nor  attacked.  Our  real  field  lies  in 
studying  the  endocrines  themselves. 

The  endocrines  likewise  respond  to  impulses  sent  to  them 
through  the  autonomic  nervous  system,  and  the  endocrines 
respond  according  to  the  strength  of  the  impulse,  but  more 
particularly  according  to  their  own  development,  capacity, 
vigor,  and  the  balance  existing  between  the  component  parts 
of  each  endocrine  gland.  The  endocrines  may  be  underactive, 
normal,  or  overactive.  They  may  increase  or  diminish  in 
power  and  in  secretory  activity  in  varying  degrees  through  the 
different  periods  of  life,  in  the  performance  of  physiological 
functions,  and  during  disease  and  infections. 

The  important  point  first  to  be  held  in  mind  is  the  normal, 
stable  balance  or  interrelation  between  the  various  endocrines 
of  the  body.  Of  equally  great  importance  is  the  preservation 
of  balance  between  the  various  hormones  produced  by  any  one 
gland.  In  the  pituitary  the  two  most  prominent  secreting  areas 
are  the  anterior  lobe  and  the  posterior  lobe.  In  the  adrenals 
we  have  the  cortex  and  medulla  totally  different  in  structure 
and  character,  as  well  as  in  the  influence  and  the  action  of  their 
respective  secretions.  In  the  ovary  we  have  the  interstitial  or 
interglandular  structure  and  the  follicular  part  of  this  gland. 
When  ovulation  takes  place  in  association  with  menstruation, 
and  probably  long  before  this,  we  have  the  false  corpus  lu- 
teum.  When  pregnancy  takes  place  we  have  the  true  corpus 
luteum.  It  is  the  corpus  luteum  which  is  responsible  for  hyper- 
thyroidism. In  the  thyroid  we  certainly  have  two  different  se- 
cretions, one  from  the  interstitial  portion  and  a  different  one 
from  the  glandular,  and  this  accounts  for  the  various  types  of 
hyperthyroidism  and  of  Basedow's  disease  aside  from  the  fact 
that  the  severe  forms  of  hyperthyroidism  are  pluriglandular  up- 
sets. In  the  pituitary  there  is  a  certain  normal  balance  of  relation 
between  the  anterior  and  posterior  lobes.  In  the  adrenals  there 
exists  what  may  be  determined  to  be  or  be  called  a  normal  bal- 


THE  BALANCE  BETWEEN   THE   ENDOCRINES  289 

ance  between  the  cortex  and  the  medulla  and  the  same  is  to  be 
said  of  the  interstitial  and  glandular  portions  of  the  ovary.  It 
must  be  stated  here  that  the  ovary  functionates  long  before  men- 
struation is  established,  probably  from  the  earliest  years,  just 
as  do  the  other  endocrines,  and  that  a  so-called  menstrual  wave 
in  the  vast  number  of  cases  is  not  looked  for,  noticed,  or  ob- 
served. It  is,  as  a  rule,  not  evidenced  by  any  type  of  reaction. 
But  in  many  cases,  if  looked  for,  there  will  be  noted  regular 
monthly  evidences  of  this  internal  process  and  in  these  cases 
it  is  productive  of  the  same  type  of  premenstrual  nerve  and 
psychic  phenomena  as  is  recognized  in  older  girls  before  each 
monthly  outpouring  of  blood  from  the  uterus.  Only  when  the 
corpus  luteum  enters  into  the  field  do  hyperthyroidism  and 
Basedow's  disease  appear  as  a  rule. 

Any  endocrine  composed  of  two  recognized  and  distinct 
parts  may  overact  in  both  or  underact  in  both.  Overactivity 
may  involve  one  part  and  the  other  may  functionate  normally. 
One  part  may  overact  and  the  other  underact.  The  important 
point  is  that  to  whatever  degree  one  part  overacts  to  the  same 
degree  may  it  overtop  and  inhibit  the  action  of  the  other,  and 
this  difference  may  not  be  made  visible  by  corresponding 
anatomical  differences  in  size  in  the  respective  parts  of  the 
glands.  Overactivity  of  the  anterior  pituitary  often  diminishes 
the  secretory  activity  and  action  of  the  posterior,  though  in 
the  early  stages  the  posterior  may  have  been  likewise  corre- 
spondingly active;  and  this  is  well  exemplified  in  acromegaly 
with  its  early  glycosuria. 

Overactivity  of  the  interstitial  ovary  may  be  associated 
with  varying  degrees  of  inhibition  of  function  of  the  glandular 
part.  The  reverse  also  holds  true.  But  persistent  corpora  lutea 
inhibit  ovulation,  inhibit  the  normal  action  of  ovarian  secre- 
tion and  rouse  the  thyroid.  Overactivity  of  the  adrenal  medul- 
la is  generally  associated  with  underactivity  of  the  cortex.  And 
here  as  in  all  glandular  organs  we  have  what  might  be  called 
two  secretions  antagonistic  to  each  other. 

What  a  vast  meaning  does  this  bear  to  the  question  of 

therapy.    Taking  these  factors  into  consideration,  we  see  how 
19 


290  THE    ENDOCRINES 

the  balance  in  any  one  gland  may  be  disturbed  and  how  we  may 
have  numerous  combinations  of  over  and  underactivity  in  the 
interrelation  between  the  various  endocrines  as  well  as  in  their 
respective  component  parts. 

If  we  study  the  action  of  the  endocrines  and  their  respec- 
tiv^e  hormones  and  recognize  the  specific  action  of  the  hormone 
on  the  body  in  general  and  on  definite  and  specific  areas  and 
functions  of  the  body,  there  is  no  need  for  introducing  into 
the  diagostic  or  therapeutic  sphere  any  complicated  or  com- 
plicating interest- in  the  autonomic  nervous  system.  We  may 
be  able  from  the  standpoint  of  therapy,  by  giving  gland  ex- 
tract, to  supply  what  is  lacking,  or  to  inhibit  excessive  func- 
tion of  any  gland  or  part  of  a  gland,  eventually  arriving  at 
rational  or  exact  therapy.  However  much  the  endocrines 
have  to  do  with  external  form  or  characteristics,  with  physical, 
visceral,  and  metabolic  functions,  they  have  as  important  and 
specific  relations  to  the  nervous  system,  to  the  mind,  to  the  in- 
stincts, to  the  emotions,  and  to  the  psyche.  And  since  every 
gland  and  its  component  parts  is  concerned  with  each  of  these 
spheres,  it  is  well  to  remember  that  over  or  underactivity  of 
any  endocrine  gland  may  be  limited  to  or  manifested  particu- 
larly in  one,  two,  three,  or  more  of  these  spheres  of  activity. 
This  explains  the  neuroses  and  the  psychoses.  Hence  the  value 
of  ovarian  extract  (whole  gland),  and  of  ovarian  residue  in  the 
treatment  of  persistent  corpora  lutea  and  of  hyperthyroidism 
and  Basedow's  disease. 

Among  its  other  functions  the  nervous  system  is  con- 
cerned with  activities  of  a  motor  and  trophic  character.  To 
illustrate.  If  the  cells  of  the  anterior  horn  are  affected  by 
toxins,  as  in  acute  anterior  poliomyelitis,  the  nutrition  of  the 
muscles  which  they  control  and  govern  is  affected.  We  do  not 
know  whether  the  normal  nutritional  control  or  domination 
exercised  by  these  cells  is  effected  solely  by  impulses  of  an  un- 
known character  sent  out  to  these  muscles  from  the  anterior 
horn  cells,  or  whether  the  protoplasm  of  these  cells  really  pro- 
duces substances  analogous  to  enzymes  which  reach  the  muscle 
fibres  along  the  motor  path  and  so  exert  a  direct  nutritional 


THE  BALANCE  BETWEEN   THE   ENDOCRINES  291 

or  chemical  influence  on  the  muscle  fibre.    Probably  both  forms 
of  energy  are  operative. 

There  seems  to  be  a  parallelism  or  resemblance  between 
this  action  of  the  anterior  horn  cells  and  the  all  important 
action  of  the  endocrine  organs.  These  endocrines  exercise 
their  influence  in  two  ways :  One  directly  through  the  au- 
tonomic system,  of  the  nature  of  an  impulse  stimulus  to  specific 
areas  of  the  organism  (for  instance,  pylorus,  intestines,  uterus, 
muscles,  etc.)  again,  and  this  is  the  all  important  point,  the 
endocrine  substances  themselves  pass  out  through  the  blood  and 
lymph  channels  directly  to  these  cells,  muscle  bundles,  struc- 
tures, and  nerve  ends  with  whose  functions  of  growth  and- 
continuity  of  function  they  are  specifically  concerned. 

When  an  emotion  is  aroused,  the  immediate  impulse  from 
the  central  nervous  system,  be  it  from  the  higher  cortical  cen- 
tres or  those  of  less  pretentious  control  (those  of  the  medulla 
oblongata,  for  example),  exerts  its  Initial  influence  on  the 
endocrines  along  the  autonomic  system,  and  also  on  the  cere- 
brospinal axis.  The  latter  is  required  for  voluntary  and  for 
reflex  motor  activity  acting  on  the  motor  system.  On  the 
other  hand,  the  visceral  structures  receive  their  specific  im- 
pulses through  the  autonomic  nervous  system  (vasomotor, 
sphincteric,  in  embarrassments,  frights,  etc.).  The  latter  sys- 
tem likewise  carries  impulses  to  the  specifically  associated  en- 
docrines. The  outpourings  from  the  latter  (endocrines),  as 
they  are  adaptively  stimulated  by  the  various  emotions,  im- 
mediately reinforce  and  continue  the  specific  type  of  activity 
instantaneously  called  forth  by  the  original  impulse.  On  the 
degrees  of  outpouring  and  on  the  variety  of  glands  so  stimu- 
lated depends  the  behavior  of  the  individual  concerned. 

If  an  emotion,  resulting  in  the  outpouring  of  the  adrenal 
secretions,  includes  adrenalin  only,  without  an  associated  ade- 
quate response  by  the  cortex  of  the  adrenal,  and  of  other 
glands,  the  emotion  is  one  of  fear  or  terror.  If  with  the  out- 
pouring of  adrenalin  there  is  an  adequate  outpouring  from  the 
adrenal  cortex,  the  emotion  tends  more  to  that  of  anger.  If 
with  this  adrenalin  outpouring  there  is  joined  an  adequate 


292  THE    ENDOCRINES 

response  by  the  posterior  pituitary,  as  is  the  case  when  the 
maternal  instinct  or  the  sex  instinct  is  roused,  it  enhances  the 
action  of  the  adrenal  medulla  or  the  cortex  or  both.  If  the 
anterior  pituitary  responds  to  an  emotion,  there  is  the  added 
element  of  strength,  as  is  likewise  the  case  with  the  adrenal 
cortex,  but  what  is  more  important,  the  presence  of  anterior 
pituitary  outpouring  adds  the  elements  of  judgment  and  self- 
possession. 

When  an  emotion  is  aroused  there  is  a  certain  action  of 
the  autonomic  nervous  system  plus  a  certain  action  of  the 
motor  apparatus  and  an  associated  action  in  one  or  other  of 
the  endocrine  structures.  These  determine  by  their  response 
the  behavior  of  the  individual  concerned  and  in  their  various 
combinations  are  characteristically  described  as  emotions  with 
definite  names ;  and  the  psychic  behavior  as  well  as  the  physical 
behavior  are  recognized  so  readily  that  by  the  facial  expression 
alone  we  label  the  various  manifestations  as  anger,  fear,  terror, 
joy,  sorrow,  etc.  The  way  an  individual  behaves  and  gives 
outward  expression  to  his  emotions  varies  according  to  his 
instincts  and  their  makeup  and  to  the  endocrine  structures, 
their  relative  strength,  and  their  associated  response,  to  any 
stimulus. 

A  person  may  ordinarily  not  be  courageous  but  under  a 
stimulus  which  rouses  an  instinct  and  its  associated  endocrine 
activity,  into  a  great  emotion,  he  or  she  may  show  the  greatest 
courage  and  heroism.  One  may  be  brave  and  yet  use  judg- 
ment. Hence  it  is  not  always  a  discredit  if  we  say  "He  who 
fights  and  runs  away,  may  live  to  fight  another  day."  A 
courageous  individual  may  be  reckless  or  foolhardy.  It  is  easy 
to  understand  how  the  maternal  instinct  and  its  associated 
gland  responses  may  be  so  aroused  that  the  outpouring  of 
posterior  and  anterior  pituitary  secretion  would  result  in  a 
glorious  or  brave  act  when  perhaps  no  other  stimulus,  acting 
on  any  other  instinct  or  producing  any  other  emotion,  could 
prompt  this  adequate  endocrine  reserve  of  energy,  force,  or 
physical  power. 


THE  BALANCE  BETWEEN   THE   ENDOCRINES  293 

I  consider  the  anterior  hypophysis  to  be  the  all-important 
gland  of  mental  maturity.  We  know  how  important  it  is  in 
association  with  the  thyroid  particularly,  in  aiding  and  causing 
proper  mental  development.  But  this  gland  gains  in  im- 
portance in  a  trophic  cerebral  sense  after  the  early  twenties. 
The  knowledge  a  person  may  acquire,  the  information  he  may 
have  gained,  when  put  into  the  melting-pot  called  experience 
and  amalgamated  as  it  should  be.  into  a  harmonious,  stable 
combination,  may  or  may  not  be  associated  with  wisdom, 
judgment,  and  philosophy.  Some  people  even  at  the  age  of 
forty  or  fifty  years  have  the  same  youthful  immaturity  of 
mind  as  in  their  younger  years.  They  have  gained  nothing  in 
mental  stability  and  have  profited  little  if  any  by  experience. 
Compared  with  what  they  might  have  been  and  what  might 
be  expected  of  them  at  this  age,  they  are,  so  far  as  wisdom  is 
concerned,  h3'poplastic,  or  morons  of  varying  degrees.  This 
comparison  is  not  based  on  any  test  as  to  the  ordinary  func- 
tions of  the  mind,  but  is  concerned  with  the  question  of  mental 
maturity.  We  might  well  expect  the  same  varying  degrees  in 
the  ripening  of  judgment  as  we  find  during  the  earlier  years 
in  the  ripening  of  body-development,  mental  development,  sex- 
development,  etc.  There  may  be  no  improvement  as  to  ma- 
turity of  mind,  there  may  be  delayed  development,  there  may 
be  a  precocious  or  an  unusual  development. 

The  thyroid  gland  is  the  gland  of  energy.  It  speeds  up 
and  activates  all  the  functions  and  organs,  even  the  tongue. 
Hyperthyroid  people  talk  more,  more  continuously  or  quickly. 
What  is  said  depends  upon  the  instincts,  emotions,  and  the 
cerebrum  which  is  being  urged  to  talk.  With  a  poorly-stocked 
cerebrum,  the  output  is  of  no  importance.  With  a  good  cere- 
brum, well-impressed  with  knowledge,  information,  a  wealth 
of  good  ideas,  the  lingual  output  is  worth  while.  The  mixture 
and  associations  of  ideas  are  personal  and  give  us  a  good  in- 
dex of  an  individual's  tastes,  likes,  emotions,  and  endocrine 
makeup.  If  such  a  mind  is  abnormally  stimulated  by  both 
thyroid  and  adrenals  and  the  person  is  of  adrenal  mentality, 
the  ideas  expressed  are  along  the  line  prompted  by  the  instincts 


294  THE    ENDOCRINES 

and  the  emotions  with  which  the  adrenals  are  concerned;  such 
as  sports,  feats  of  strength,  pugnacity,  physical  fear,  anger, 
and  possibly  certain  forms  of  sex  questions. 

If  the  cerebrum,  stimulated  by  thyroid,  is  actively  stimu- 
lated by  the  posterior  pituitary,  thought  and  talk  may  be  along 
lines  of  the  instincts  and  emotions  with  which  this  portion  of 
the  pituitary  gland  is  associated,  such  as  feminine  matters, 
romance,  children,  phobias,  anxieties,  suspicions,  or  along  sex 
lines. 

I  believe  the  anterior  pituitary  to  be  associated  not  only 
or  always  with  strength  of  body  but  decidedly  with  strength 
of  mind.  Its  normal  activities,  so  far  as  its  trophic  connection 
with  the  brain  is  concerned,  lead  to  mental  maturity,  to  judg- 
ment, to  philosophy,  to  self-control.  Under  associated  thyroid 
stimulation,  an  individual  with  such  an  anterior  lobe  would 
show  wisdom,  and  in  this  class  fall  the  wise,  the  elder  states- 
men. Since  the  anterior  hypophysis  is  a  gland  whose  activities 
are  associated,  if  we  might  so  say,  with  intellectual  instincts 
and  emotions  and  with  the  control  of  the  other  instincts  and 
emotions,  either  or  both  of  these  activities  lend  themselves  to 
the  development  of  brain  character  of  the  better  sort.  The 
anterior  pituitary  when  dominant  and  in  control,  may  control 
the  activity  or  inhibits  the  activity  of  the  sex  glands,  the  pos- 
terior pituitary,  the  adrenal  cortex,  and  the  testis,  etc. 

Viewing  the  hypophysis  gland  from  the  standpoint  of  its 
relation,  in  a  trophic  sense,  to  the  genital  tract  and  to  sex  func- 
tion, we  must  take  into  consideration  both  the  anterior  and 
the  posterior  lobes.  Proper  secretory  activity  on  the  part  of 
the  hypophysis  is  essential  to  normal  development  of  the  uterus, 
tubes,  and  ovaries.  The  anterior  lobe  is  concerned  with  growth 
in  general,  stimulates  the  development  of  the  body,  bone,  mus- 
cle, and  mind,  and  therefore  includes  within  the  sphere  of  its 
activity  the  sex  organs.  During  pregnancy  the  anterior 
lobe  undergoes  specific  stimulation  in  its  structure  and  activity, 
and  the  resulting  changes  in  the  gland  are  so  marked  and  dis- 
tinctive that  after  labor,  certain  of  these  structural  alterations 
remain.     It  can  be  readily  understood  that  the  anterior  pitui- 


THE  BALANCE  BETWEEN   THE   ENDOCRINES  295 

tary,  as  well  as  other  glands,  may  therefore  bear  an  important 
relation  in  the  way  of  stimulation,  to  growth  as  regards  the 
embryo. 

In  the  early  stages  of  acromegaly,  there  appears  to  be 
an  overstimulation  in  the  genital  tract  followed  later  by  evi- 
dences of  diminished  stimulation,  and  thereafter  regressive 
changes  and  atrophy  occur  in  the  genital  tract.  But  this  early 
stimulation  is  part  of  the  general  growth  associated  with 
acromegaly  and  is  not  more  specifically  related  to  the  sex 
organs  at  this  time  than  it  is  to  other  areas  of  the  body.  In 
addition,  the  posterior  lobe  likewise  is  overactive  at  first. 

The  subsequent  regression  in  the  genital  tract  is  due  partly 
CO  the  diminution  of  posterior  lobe  activity,  since  this  part  of 
the  gland  is  much  more  specifically  related  to  trophic  support 
of  the  genitalia  than  is  the  anterior  part  of  the  gland.  The 
posterior  lobe,  from  which  is  obtained  pituitrin,  has  the  well- 
known  action  during  labor  since  it  increases  the  force  of  the 
uterine  muscle  contractions.  It  is  the  gland  whose  secretion 
is  responsible  for  the  Braxton  Hicks'  painless  contractions  of 
pregnancy,  for  the  normal  rhythmic  contractions  of  the  non- 
pregnant uterus  which  aid  in  keeping  the  uterine  musculature 
normal  in  character  and  tone;  for  the  excessive  contractions 
during  menstruation  which,  in  so  many  cases,  constitute  the 
physical  annoyance  called  dysmenorrhea.  When  labor  is  in- 
stituted the  posterior  pituitary  evidences  its  specific  contractile 
functions  in  heightened  form  by  producing  the  physiological 
labor  pains  during  what  is  really  an  endocrine  crisis,  that  is, 
labor.  To  develop  a  uterus  normally,  a  girl  must  possess  suf- 
ficient of  the  trophic  element  of  the  various  glands  which  stimu- 
late body  growth  in  general,  and  among  the  most  important 
of  these  is  the  anterior  pituitary.  She  must,  however,  possess 
enough  of  the  trophic  element  which  in  addition  specifically 
and  regularly  produces  painless  uterine  automassage  or  con- 
tractions and  this  is  furnished  by  the  posterior  lobe  of  the 
pituitary.  A  lack  of  sufficient  secretion  from  one  or  the  other 
or  a  relative  insufficiency  of  both  or  of  either  give  us  the  varied 


296  THE    ENDOCRINES 

degrees  of  infantile  uterus,  uterine  hypoplasia,  or  delayed  de- 
velopment of  the  uterus 

After  normal  size  and  development  of  the  internal  geni- 
talia have  been  attained,  insufficient  action  on  the  part  of  the 
posterior  lobe  is  responsible  for  atrophy  of  the  uterus.  While 
failure  of  development  may  be  due  to  a  minus  of  the  anterior 
lobe  in  the  early  years,  minus  of  the  posterior  is  in  adult  life 
the  much  more  important  factor  in  causing  atrophy.  My 
therapeutic  endeavors  indicate  that  the  administration  of  an- 
terior pituitary  extract  in  fibromyomatous  tumors  of  the  uterus 
has  an  action  totally  opposed  to  the  stimulating  trophic  effect 
which  the  posterior  lobe  exerts  upon  the  uterus  and  on  men- 
strual function.  To  repeat,  while  the  anterior  lobe  is  im- 
portant in  the  early  years  for  the  development  of  the  genitalia, 
it  is  the  posterior  lobe  which  is  important,  especially  later, 
for  preserving  the  normality  of  what  has  been  developed,  and 
it  is  in  the  posterior  pituitary  that  we  possess  the  important 
trophic  factor  which  through  overactivity  is  responsible  for 
fibromyomata.  It  is  probable  that  the  anterior  lobe  increases 
the  connective-tissue  elements  of  the  uterus  and  the  posterior 
lobe  is  related  to  the  muscular  fibres.  Fibrosis  uteri  is  a  result 
of  frequent  and  repeated  pregnancy  and  it  is  known  that  after 
each  pregnancy  there  is  a  tendency  to  an  increase  of  the  con- 
nective-tissue bundles.  In  acromegaly  the  muscular  tissue  of 
the  body  evidences  changes  of  this  type.  It  is  therefore  con- 
ceivable that  myomata  are  due  to  the  posterior  pituitary  over- 
activity. Fibrosis  uteri  and  pure  fibroids  may  be  due  partly 
to  anterior  lobe  activity.  Fibromyomata  are  due  to  a  com- 
bined overaction  of  the  two  lobes  exerted  specifically  on  the 
uterus,  with  the  role  of  the  posterior  lobe  as  the  important 
factor.  Hence  in  pure  fibromata  (anterior  lobe),  there  should 
be  less  tendency  to  glycosuria  than  in  myomata,  since  the  lat- 
ter are  due  to  posterior  lobe  overactivity.  I  have  a  history  of 
three  sisters  with  fibromyomata,  on  two  of  whom  I  myself 
have  operated.  The  three  sisters  have  the  same  father.  One 
is  born  of  the  first  wife,  the  other  two  of  the  second.  The 
point  of  heredity  in  this,  showing  the  transmissibility  of  gland 


THE  BALANCE   BETWEEN   THE   ENDOCRINES  297 

instability  or  of  gland  dominance,  is  that  the  father,  a  man  of 
small  stature,  shows  from  the  description  which  has  been 
given,  all  the  evidences  of  a  physical  nature  of  anterior  pitui- 
tary lobe  minus.  He  is  small  and  so  are  the  children,  has  had 
little  hair  on  the  face  in  the  way  of  beard,  has  little  hands  and 
little  feet.    A  son  has  "nodules"  of  the  scalp. 

The  ovary 'has  at  least  two  if  not  four  structures  capable 
of  producing  a  secretion:  (1)  The  follicle  apparatus.  (2) 
The  stroma  or  interglandular  apparatus  including  those  typical 
interstitial  cells  said  to  parallel  the  interstitial  cells  of  Leydig 
in  the  testis.  (3)  After  ovulation  is  established  we  have  the 
ripening  and  rupturing  Graafian  follicles  and  the  corpus  luteum 
of  menstruation.  (4)  When  pregnancy  takes  place  the  corpus 
luteum  which  gives  out  the  ovum  continues  to  develop  for 
several  months,  through  the  reaction  and  stimulation  produced 
by  the  decidua  and  especially  by  the  growing  ovum.  The 
secretion  produced  by  the  growing  ovum  is  a  secretory  cell 
off-throw  from  its  outer  covering  called  the  trophoblast.  From 
this  trophoblast  develop  the  future  chorion  and  placenta. 

Now  the  follicular  apparatus  of  the  ovary  is  influenced 
by  and  related  to  menstruation.  The  menstrual  and  premen- 
strual activity  of  the  ovary  calls  into  play,  and  is  associated 
with,  activity  of  the  posterior  pituitary,  the  adrenals  and  the 
thyroid.  The  relation  of  follicular  function  is  particularly 
dependent  on  normal  posterior  pituitary  stimulation.  It  is  the 
follicle  apparatus  which  stimulates  the  adrenal  medulla  while 
the  interstitial  portion  of  the  ovary  stimulates  the  adrenal  cor- 
tex and  the  anterior  pituitary.  The  corpus  luteum  stimulates 
the  glandular  thyroid  and  is  supposed  to  inhibit  overactivity 
of  the  posterior  pituitary,  but  it  often  rouses  the  post  pituitary. 

The  interstitial  ovary  is  a  secretory  tissue  which  acts, 
probably  in  association  with  the  immature  follicles,  long  before 
menstruation  is  established  and  this  activity  is  evidenced  by 
the  fact  that  the  physical  conformation  of  a  girl  and  the 
secondary  sex  characteristics  are  in  evidence  before  menstrua- 
tion is  established.  If  we  bear  in  mind  the  picture  of  ovary 
(follicular),  adrenal  medulla,  posterior  pituitary,  and  thyroid 


298  THE    ENDOCRINES 

(glandular)  as  the  more  predominant  relation  in  the  girl,  and 
testis,  adrenal  cortex,  and  anterior  pituitary  and  thyroid  inter- 
stitial, as  the  more  predominant  in  the  boy,  we  can  then  rea.dily 
understand  the  difference  in  the  shape  of  the  pelvis  in  the  two 
sexes,  a  difference  in  the  skeletal  structures  and  in  the  muscles, 
the  difference  in  the  distribution  of  hair  and  fat,  and  the  marked 
difference  in  taste,  emotions  and  inclination.  In  the  male  we 
have  in  the  gonads  a  different  relation  or  type  of  secretion, 
especially  when  we  consider  what  are  known  as  the  interstitial 
cells  of  Leydig.  To  the  gonads  of  the  boy,  before  puberty  as 
well  as  after,  must  be  attributed  a  secretory  action,  since  it  is 
already  then  indicated,  by  the  differences  called  secondary  sex 
characteristics.  These  differences  become  very  evident  and 
more  marked  as  boy  or  girl  advances  towards  puberty  and  on 
through  adolescence.  And  so  in  the  boy  or  girl  deviations  to 
the  female  type  in  the  boy  or  deviations  to  the  male  type  in  the 
girl  have  a  significance  which  from  the  standpoint  of  therapy 
should  not  be  underestimated. 

Therefore  there  are  only  two  possible  explanations  for 
these  marked  differences  in  sex  characteristics  and  in  the  in- 
stincts, emotions,  tastes,  and  play  of  the  two  sexes.  Either  the 
ovary  contributes  a  secretion  directly  responsible  for  these 
secondary  sex  characteristics  (as  mammary  glands,  etc.)  or 
these  characteristics  result  through  modifications  produced  by 
the  glandular  ovary  in  pituitary,  adrenals,  thyroid,  and  other 
glands,  or  else  both  factors,  as  is  probable,  enter  into  consid- 
eration with  the  latter  factor  of  most  importance. 

The  gonads  of  the  boy  and  man  either  produce  a  secre- 
tion directly  responsible  for  the  secondary  sex  characteristics, 
the  subsequent  distribution  and  growth  of  beard,  etc.,  or  else 
these  effects  are  produced  likewise  by  gonadal  Leydig  stimu- 
lation of  associated  glands.  It  is  probable  that  both  factors 
hold  true,  with  the  latter  factor  of  most  importance.  The 
ovaries  are  giving  off  their  secretion  from  birth  on.  Ordinarily 
the  corpus  luteum  of  menstruation  should  appear  at  puberty, 
but  it,  often  enough,  develops  in  earlier  years  and  is  so  respon- 
sible for  much  that  has  been  overlooked. 


THE  BALANCE  BETWEEN   THE   ENDOCRINES  299 

Early  ripening  of  the  ovaries  and  the  girl's  early  entrance 
into  the  menstrual  function  hasten  those  changes  in  the 
epiphyses  which  inhibit  growth  in  bone  length.  This  results 
in  shorter  stature.  This  is  produced  by  a  stimulation  of  the 
posterior  lobe  of  the  pituitary  and  a  consequently  lesser  degree 
of  stimulation  or  a  relative  inhibition  of  the  anterior  lobe  of 
the  pituitary.  Tall,  thin  stature  may  likewise  result  from  the 
same  form  of  overstimulation  of  the  adrenal  medulla  as  com- 
pared with  the  cortex.  On  the  development  of  menstruation, 
the  posterior  pituitary  and  the  adrenals  enter  into  still  greater 
play  with  the  glandular  part  of  the  thyroid  in  the  processes 
associated  with  menstruation.  If  the  posterior  pituitary  en- 
ters early  into  greater  activity  than  normal,  it  may  to  this 
degree  relatively  or  actually  "overtop"  the  action  of  the  an- 
terior lobe. 

Late  ripening  of  female  and  the  male  gonads  may  be  as- 
sociated with  tall  stature.  It  is  well  known  that  in  eunuchs 
tall  stature  results  after  castration.  Since  the  cells  of  Leydig, 
etc.,  no  longer  stimulate  the  adrenal  cortex,  and  all  stimula- 
tion of  the  pituitary  is  diminished,  adrenal  medulla  growth  in 
stature  takes  place.  The  removal  of  this  pituitary  stimulation 
is  of  the  type  which  causes  a  loss  of  balance,  in  this  sense 
that  the  posterior  pituitary  diminishes  in  activity  relatively 
less  than  does  the  anterior  lobe.  As  a  result  of  anatomical 
studies  in  eunuchs  there  is  noted  an  excessive  growth  and 
action  of  the  pituitary  and  this  becomes  evident  in  association 
with  overactivity  of  the  adrenal  medulla  in  changes  in  the 
voice,  absence  of  hairiness,  tall  stature,  but  not  the  broad, 
thick,  powerful  chest.  Primary  excessive  action  of  the  an- 
terior pituitary  instead  of  stimulating  the  ovaries  inhibits  their 
activity,  as  I  have  proven  often  enough  by  therapy.  So  marked 
is  the  effect  of  well-developed  acromegaly  on  the  ovaries,  since 
posterior  lobe  activity  is  often  correspondingly  diminished  that 
many  have  been  tempted  to  consider  ovarian  insufficiency  as 
the  cause  of  acromegaly  rather  than  the  result  of  the  same, 
and  both  types  of  etiology  are  certainly  possible.  Just  as  de- 
ficient normal  ovarian  function  may  result  in  increased  body- 


300  ,  THE    ENDOCRINES 

length  because  of  a  relative  overactivity  on  the  part  of  the  an- 
terior lobe  through  lack  of  proper  stimulation  of  the  posterior, 
so  the  reverse  may  be  true.  It  must  be  remembered  that  this 
element  of  growth  in  body  length  is  considered  during  the 
period  of  adolescence  mainly. 

With  these  and  many  other  facts  in  mind,  it  is  more  than 
suggestive  that  the  two  secretions  of  the  ovary  and  of  the  testis 
act  not  only  by  virtue  of  these  secretions  exerted  specifically  on 
certain  areas  and  processes  of  the  body,  but  that  they  do  so 
more  decisively  by  varying  degrees  of  stimulation  and  inhibi- 
tion of  the  associated  endocrines,  and  that  differences  in  the 
balance  between  the  interstitial  and  glandular  part  of  ovary  or 
of  testis  are  of  huge  importance. 

Man  is  more  hairy  because  his  gonads  act  directly  on  hair 
growth  or  more  probably  because  the  cells  of  Leydig  stimulate 
the  hair-producing  function  of  the  adrenal  cortex  and  the  an- 
terior pituitary.  Woman  is  less  hairy  because  the  interstitial 
ovarian  secretion  cannot  so  stimulate  growth  of  hair  on  the 
face,  chin,  chest,  back,  and  legs.  The  interstitial  gland  of  the 
ovary  cannot  stimulate  this  function  in  the  adrenals  as  much 
as  do  the  specific  cells  of  Leydig.  In  addition,  however,  the 
glandular  ovary  stimulates  the  adrenal  medulla  and  inhibits 
activity  of  the  adrenal  cortex.  The  glandular  ovary  stimu- 
lates the  posterior  pituitary  and  relatively  inhibits  the  anterior 
pituitary.  The  interstitial  ovary  stimulates  the  anterior  pitui- 
tary and  adrenal  cortex  and  relatively  inhibits  posterior  lobe 
activity  so  that  differences  in  balance,  if  marked,  in  the  ovary 
have  an  influence  on  body  growth.  The  interstitial  ovary 
stimulates  one  part  of  the  thyroid,  the  glandular  ovary  the 
other,  but  the  corpus  luteum  of  pregnancy  stimulates  the  gland- 
ular thyroid  and  the  adrenal  medulla,  but  pregnancy  inhibits 
the  posterior  pituitary.  Overactivity  of  the  posterior  pituitary 
during  pregnancy  is  responsible,  at  least  in  part,  for  nausea 
and  vomiting,  for  the  toxemia  of  pregnancy,  etc.  Together 
with  thyroid  minus  it  is  responsible  for  the  eclamptic  and  pre- 
eclamptic states.     That  it  is  related  to  the  formation  of  gall- 


THE  BALANCE  BETWEEN   THE  ENDOCRINES  301 

Stones  and  is  responsible  for  high  blood  pressure  seems  quite 
clear. 

Men  vary  for  these  reasons  in  the  hairy  growth  on  the 
body  and  face  and  in  the  type  of  its  distribution.  Women 
vary  in  the  type  of  distribution  of  hair  and  in  many,  more 
especially  about  the  menopause  period,  when  there  is  a  re- 
arrangement of  the  gland  relations,  there  are  varying  degrees 
of  hair  growth  on  face  and  chin.  Because  of  an  atypical  inter- 
glandular  relation,  many  women  from  their  earlier  years  have 
hair  on  the  arms,  thighs,  and  body  of  the  male  type.  There- 
fore, while  there  may  be  less  hair  and  beard  than  usual  in 
many  men,  there  may  be  more  hair  than  normal  on  body  and 
face  in  many  women.  It  is  more  suggestive  to  say  that  in  the 
female,  ovarian  secretion,  by  failure  to  inhibit  the  specific 
hair  function  of  the  adrenals  and  the  hypophysis,  has  resulted 
in  hairy  growth  resembling  that  noted  in  men.  There  is  in  men 
more  adrenal  cortex  function  and  relatively  speaking,  greater 
function  in  the  anterior  pituitary  than  in  the  adrenal  medulla 
and  posterior  pituitary  respectively,  though  the  function  of  the 
latter  two  may  be  either  normal,  increased,  or  deficient.  In 
men,  failure  to  stimulate  hairiness  points  to  actual  or  relative 
diminution  of  adrenal  cortex  function  and  to  actual  or  relative 
diminution  of  the  anterior  pituitary.  With  this  condition  the 
adrenal  medulla  or  the  posterior  pituitary  activity  may  be  of 
varying  grades. 

Now  the  posterior  pituitary,  important  as  is  its  action  in 
men,  is  less  essential  to  the  sex  functions  and  sex  urge  in  them 
because  of  the  added  effects  of  the  adrenal  cortex  and  the  cells 
of  Leydig.  The  posterior  pituitary  certainly  has  a  specific 
action  on  the  uterus  during  labor.  It  is  partly  responsible  for 
the  tender  emotions  in  women.  Women  have  smaller  hands 
and  feet.  They  have  a  typical  distribution  of  the  normal 
fat  of  the  body,  they  have  no  beards.  Therefore  it  is  rational 
to  conclude  that  the  posterior  pituitary,  in  close  association 
with  the  ovary,  the  glandular  thyroid,  and  the  adrenal  medulla, 
is  responsible  not  only  for  the  secondary  sex  characteristics 
typical  of  the  female,  but  for  her  tender  emotions  and  her  emo- 


302  THE    ENDOCRINES 

tional  tendencies.  If  in  a  man  the  posterior  pituitary  is  not 
overtopped  by  the  anterior,  and  the  adrenal  medulla  by  the 
cortex,  his  tender  emotions  are  present. 

Since  the  anterior  pituitary,  in  association  with  the  adrenal 
cortex  is  concerned  with  growth,  development  of  the  hands 
and  feet,  of  bone,  of  broad,  thick  chest,  and  the  element  of 
strength,  it  is  suggestive  that  the  male  gonads  stimulate  those 
glands  and  make  their  activities  more  evident  in  men  than  in 
women.  This  does  not  alter  the  fact  that  a  primary  inherited 
anterior  pituitary  overactivity  or  one  acquired  through  inter- 
current causes  (study,  etc.),  while  associated  with  growth  in 
stature  or  growth  of  mind  may  not  be  associated  with  an  ade- 
quately good  adrenal  cortex  or  gonadal  structure. 

However  much  the  anterior  pituitary,  through  stimulating 
general  growth,  may  have  to  do  with  development  of  the 
uterus,  an  associated  adequate  activity  of  the  posterior  lobe  is 
of  the  greatest  nutritional  importance  to  the  genitalia.  The 
posterior  lobe  takes  a  most  specific  and  active  part  in  men- 
struation and  labor,  and  is  the  most  important  causative  factor 
in  dysmenorrhea.  It  is  therefore  more  than  suggestions  (and 
therapy  in  many  cases  to  be  reported  verifies  this  contention), 
that  an  overactivity  of  both  anterior  and  posterior  lobes  up  to 
a  certain  age  is  responsible  for  a  large  size  of  the  uterus,  for 
elongated  uteri,  for  elongatio  colli.  After  the  developmental 
stage  has  been  passed,  the  posterior  lobe  is  the  important  nu- 
tritional factor  and  its  overactivity  is  the  most  important  ele- 
ment in  the  production  of  fibromyomata,  whereas  fibrosis  uteri 
probably  bears  a  relation  to  anterior  lobe  activity  also. 

In  my  obstetric  experience  between  ten  and  twenty  per 
cent,  of  pregnant  women  evidence  to  the  tactile  sense  fibro- 
matous  or  myomatous  nodules  in  the  uterus  in  the  latter  months 
of  pregnancy.  These  are  distinctly  recognized  by  the  external 
hand  after  the  placenta  has  been  expelled  and  uterine  contrac- 
tion has  taken  place.  Subsequent  bimanual  examination  con- 
firms this  diagnosis.  It  is  remarkable  how  nursing,  as  it 
brings  the  uterus  back  to  its  normal  involution,  usually  aids 
in  the  total  disappearance  of  these  nodules  which  may  be  iso- 


THE  BALANCE  BETWEEN   THE   ENDOCRINES  303 

lated  or  discrete,  single  or  g-enerally  multiple.  Since  when  the 
mother  nurses,  they  disappear  entirely  after  a  few  weeks,  as  a 
rule,  such  as  disappear  are  recognized  to  be  myomata  rather 
than  fibromata;  such  as  do  not  disappear  are  fibromata.  The 
above  discussion  serves  to  illustrate  the  reason  for  my  referring 
to  the  anterior  hypophysis  as  more  of  a  male  than  a  female 
portion  of  the  gland ;  it  does  more  work  in  the  development  of 
the  body,  in  the  production  of  strength  and  maturity  of  mind, 
and,  in  association  with  the  adrenal  cortex,  and  cells  of  Leydig, 
and  the  interstitial  thyroid  is  responsible  for  masculine  instincts 
and  emotions. 

The  reason  for  calling  the  posterior  lobe  more  a  female 
gland  than  a  male  gland  is  because  of  its  specific  action  during 
menstruation,  pregnancy,  and  labor,  and  because  its  other 
activities,  in  association  with  the  adrenal  medulla,  the  glandular 
thyroid  and  the  ovary  and  the  corpus  luteum  are  evidenced  in 
the  feminine  instincts,  emotions,  and  psyche. 

Hence,  in  whatever  respect  or  degree  a  woman  resembles 
the  male  in  body  form,  size,  distribution  of  hair,  instincts,  emo- 
tions, and  tastes,  to  that  degree  is  my  attention  attracted  to  the 
adrenal  cortex  or  the  anterior  pituitary  or  both  and  to  the  in- 
terstitial ovary. 

To  whatever  degree  or  extent  the  male  resembles  the  fe- 
male in  shape  of  pelvis,  hands,  distribution  of  hair,  lack  of 
beard,  tastes,  instincts,  and  emotions,  to  that  degree  do  I  in- 
cline to  the  notion  of  actual  or  relative  preponderance  of  the 
posterior  pituitary  and  the  adrenal  medulla  as  compared  to  the 
normal  balance  expected  in  his  sex. 

Among  the  functions  of  the  adrenal  medulla  (adrenalin) 
is  the  preservation  of  the  tonus  of  the  organs  innervated  by 
the  sympathetic,  and  of  course  to  that  extent  these  organs  and 
their  function  are  dependent  on  the  adrenal  medulla.  It  main- 
tains the  sugar  content  of  the  blood.  It  is  concerned  with  the 
regulation  of  blood-pressure  and  the  distribution  of  the  blood. 
It  increases  the  excitability  of  the  striated  muscles;  it  relaxes 
the  stomach  and  intestines,  and  contracts  the  pyloric  and  ileoce- 
cal sphincters  and  the  internal  sphincter  of  the  anus. 


304  THE    ENDOCRINES 

Under  conditions  tending  to  induce  fear,  if  the  adrenal 
output  is  adequate  to  produce  and  enhance  these  normal  pro- 
cesses with  a  certain  degree  of  intensity,  and  if  the  cortex, 
especially  if  associated  with  the  action  of  other  endocrines, 
acts  in  harmony,  the  individual  shows  fright  of  varying  de- 
grees, is  able  to  run  away  and  to  show  judgment.  If  the  added 
action  of  the  adrenal  cortex  is  of  sufficient  intensity,  the  emo- 
tion aroused  is  anger.  This  is  of  varying  degrees  of  intensity 
and  is  associated  with  the  instinct  of  pugnacity.  If,  on  the 
contrary,  there  is  no  adequate,  associated,  balanced  response 
by  the  adrenal  medulla,  by  the  adrenal  cortex,  or  the  posterior 
or  anterior  pituitary,  the  emotion  of  fear  becomes  that  of  terror 
with  inability  to  flee,  total  disorganization  of  physical,  mental, 
and  psychic  processes.  The  adrenal  cortex  is  among  the  other 
gland  outpourings  necessary  to  stabilize  the  above-mentioned 
physical  and  psychic  processes  and  the  processes  produced  by 
action  of  adrenal  medulla  and  chromaffin  system. 

Since  the  thyroid,  if  normal  or  overactive,  accentuates 
other  functions  and  emotions,  a  hyperthyroid  person  will  show 
to  an  exaggerated  degree  any  of  the  emotions  dependent  on 
good  or  faulty  endocrine  response.  The  cowardly  manifest 
the  physical  tendencies  to  retreat  and  to  flee.  In  the  intense 
degrees  of  fright,  called  terror,  there  may  be  even  relaxation 
of  the  sphincters,  a  condition  which  is  the  reverse  of  that  pro- 
duced by  normal  adrenal  sufficiency. 

The  courageous  go  forward  or  hold  their  ground.  In 
the  emotion  of  anger  attending  the  instinct  of  pugnacity  not 
only  does  the  adrenal  medulla  functionate  actively,  but  there 
must  be  a  corresponding  activity  and  stimulation  of  the  cortical 
portion.  In  other  words,  an  individual  is  fearsome  in  varying 
degrees  primarily  according  to  the  degree  of  adrenal  and  pitui- 
tary response  to  stimuli.  An  individual  Is  courageous  and 
bold  partly  because  of  good  adrenal  response,  both  medullary 
and  cortical. 

The  type  of  courage  depends  on  the  element  of  judgment 
and  self-control.  A  person  may  be  courageous  but  not  fool- 
hardy, or  he  may  be  reckless  or  thoughtless.     What  would 


THE  BALANCE  BETWEEN   THE   ENDOCRINES  305 

ordinarily  be  fear  or  terror  may  be  manifested  as  anger  or 
courage  if  an  associated  emotion  brings  into  play  another  en- 
docrine associated  with  that  other  emotion.  For  instance,  the 
posterior  pituitary,  which  is  associated  with  the  maternal  in- 
stinct, will  respond  when  that  instinct  and  its  associated  emo- 
tion are  aroused,  and  it  then  reinforces  the  action  of  the  adre- 
nals, for  instance,  in  a  state  related  to  fear.  In  the  manifesta- 
tions of  fear,  anxiety,  suspicion,  etc.,  related  as  they  are  to  the 
adrenal  medulla  and  the  posterior  pituitary,  the  associated 
behavior  of  the  cortex  and  the  other  endocrines  is  important 
in  determining  the  variations,  the  degrees  of  severity,  and  the 
direction  and  duration  of  these  states. 

Phobias  and  anxieties  associated,  for  instance,  with  ab- 
normal or  excessive  coitus  point  to  weakness  or  diminution  in 
activity  on  the  part  of  the  adrenal  cortex.  Then  the  character 
of  this  abnormal  state  is  influenced  and  determined  by  the  char- 
acter and  interrelation  of  the  anterior  pituitary,  posterior  pitui- 
tary, thyroid,  etc.  The  greater  is  the  associated  activity  of  the 
anterior  pituitary,  the  greater  are  the  judgment  and  element 
of  control  in  these  states  of  anxiety.  The  action  of  the  anterior 
pituitary  in  states  of  anger  and  under  conditions  requiring 
courage  assists  in  directing  the  course  of  action.  Of  course, 
we  must  include  the  previous  influence  of  the  anterior  pituitary 
on  the  cerebrum,  etc.,  as  well  as  its  response  in  an  emergency. 

The  endocrines  are  therefore  closely  related  to  sleep,  the 
production  of  sleep,  to  sleeplessness,  to  the  dreamy  waking 
state,  and  to  dreams.  The  endocrines  stimulate,  arouse,  and 
recall  in  the  lower  and  partly  in  the  upper  consciousness  emo- 
tional memory  pictures.  Whatever  action  the  original  event, 
occurrence,  or  picture  roused  in  them  in  the  way  of  response 
to  an  emotion,  their  activity  and  action  during  sleep  brings 
back  the  same  or  a  symbolic  picture  in  the  brain. 

Now  the  brain,  while  it  may  be  likened  to  a  cinema  film 
with  the  power  of  recall  in  picture  form  of  the  exposures  to 
stimuli  and  events,  must  be  thought  of  as  consisting  of  millions 
of  little  paths,  each  of  which,  while  distinct,  has  communica- 
tions with  other  paths.    The  path  from  without  inward  repre- 


306  THE    ENDOCRINES 

sents  a  point  in  the  brain  where  an  impression  was  made 
through  any  of  the  senses,  a  continuation  through  the  brain 
and  through  nerves  of  two  kinds :  one  the  nervous  system 
which  prompts  muscular  action,  the  other,  more  important  for 
the  understanding  of  our  problem,  nerves  associated  with 
glands  and  the  internal  organs  of  the  body,  which  internal 
organs  and  which  glands  act  in  a  specific  manner  according  to 
the  stimulus.  This  latter  mechanism  is  the  mechanism  of  the 
instincts  and  the  emotions,  the  autonomic  nervous  system; 
the  former  mechanism  produces  those  muscular  responses 
which  are  likewise  typical  for  the  various  emotions.  This 
latter  action  creates  a  smile,  a  frown,  the  tearful  face,  the 
attempt  to  strike  a  blow,  the  warding  off  of  a  blow,  flight,  etc. 

This  outward  physical  manifestation  as  well  as  the  im- 
pulse to  do  must  be  kept  distinctly  separate  from  the  processes 
of  internal  reaction  in  the  heart,  blood-vessels,  blood-stream, 
etc.,  and  from  the  action  of  the  internal  secretory  glands  which, 
as  stated  before,  act  typically  in  association  with  the  emotions 
produced  by  stimuli. 

Now  the  whole  problem  depends  upon  several  facts  which 
must  be  held  in  mind.  ( 1 )  Repetition  of  the  same  stimuli  may 
sensitize  the  path  and  sensitizes  the  reaction.  (2)  This  sensi- 
tiveness of  any  path  or  paths  may  be  diminished  by  switching 
the  course  of  the  stimulus  into  other  paths.  (3)  To  whatever 
degree  any  path  or  paths  are  made  oversensitive  by  use  they 
overshadow  other  paths  and  attract  into  the  sensitized  paths 
a  stimulus,  which,  without  this  element  of  enhanced  attraction 
or  invitation,  might  have  gone  into  some  other  path.  There- 
fore any  instinct,  if  it  is  stronger  than  another,  is  so  because 
the  mechanism  of  attraction  is  more  powerful  in  one  field  of 
paths  than  in  other  fields  of  paths.  Let  us  remember  that  at 
the  end  of  each  path  is  an  endocrine,  or  endocrines.  And 
since  everyone  is  born  with  instincts  and  emotions  of  varying 
types  and  degrees  of  intensity,  stimuli  follow  what  is  for  that 
individual  the  course  of  least  resistance  or  greatest  attraction. 
Now  it  is  possible  to  develop  and  widen  and  sensitize  paths 
by  use.     It  is  possible  to  anesthetize  paths  by  disuse.     It  is 


THE  BALANCE  BETWEEN   THE   ENDOCRINES  307 

possible  by  diversions  or  switches  to  alter  the  course  or  path 
which  any  stimulus  may  follow,  and  the  ability  to  accomplish 
these  results  depends  firstly  on  the  inborn  physical  qualities 
and  on  the  effects  of  treatment  or  training,  and  subsequently 
on  what  we  call  self-control.  In  other  words,  during  child- 
hood and  the  early  years,  the  parents  should  be  the  switchmen 
and  the  flagmen ;  during  the  same  period  and,  of  course,  much 
more  so  as  the  child  grows  older  and  in  adult  life,  the  individ- 
ual concerned  is  his  own  switchman  and  flagman. 

The  whole  problem  of  dreams  depends  to  a  great  extent 
upon  the  theory  of  a  reverse  of  this  action ;  that  is,  any  endo- 
crine activity  which  is  or  has  been  the  end  result  of  a  stimulus 
associated  with  an  experience  or  an  emotion  may  by  a  reverse 
of  the  primary  course  be  responsible  for  the  recall  of  the  reg- 
istered stimulus  or  its  like,  though  this  resemblance  may  not 
always  be  apparent.     Hence  the  term,  symbolism. 

The  tremendous  error  of  the  Freudian  idea  is  the  stress 
that  it  laid  on  the  sex  instinct.  It  is  a  strong  instinct,  but 
other  instincts  and  emotions  are  of  as  great  if  not  greater  im- 
portance in  their  association  with  neuroses  and  psychoses.  The 
latter  are  produced  much  more  often  by  change  in  the  thyroid, 
in  the  suprarenals,  in  the  parathyroids,  or  especially  in  the 
pituitary.  The  contra-suggestive  individual  is  of  all  the  people 
in  the  world  most  likely  to  be  unhappy.  The  individual  whose 
instinct  of  subjection  is  all  too  marked  may  find  his  lot  in  life 
extremely  difficult.  The  too  suggestible  individual  is  readily 
led  into  temptation.  A  person  with  the  gregarious  instinct 
strong  in  him  and  who  spends  his  or  her  life  on  an  isolated 
farm,  is  apt  to  be  unhappy,  and  it  is  the  gregarious  instinct 
which  takes  him  or  her  from  the  farm  to  the  large  city.  It  is 
this  gregarious  instinct  which  keeps  millions  of  people  in  mis- 
erable surroundings  and  under  the  influence  of  unwholesome 
conditions  when  otherwise  they  might  be  much  happier  on  a 
farm.  The  instinct  of  curiosity,  much  as  It  leads  to  scientific 
investigations,  leads  to  most  erroneous  views  of  sex  questions 
unless  correct  interpretations  and  explanations  are  given,  and 
if  the  Freudians  have  done  one  thing  more  than  many  others 


308  THE    ENDOCRINES 

\Yhich  have  done  harm  it  is  that  they  have  laid  such  stress  on 
one  instinct  and  have  created  misunderstandings  and  morbid 
interest  in  that  phase  of  Hfe  which  should  not  play  an  all  im- 
portant part  in  the  thoughts  of  the  individual.  I  know  many 
men  whose  nervousness  and  irritability  are  due  entirely  to  the 
worry  about  their  stock  exchange  speculations ;  I  could,  there- 
fore, if  I  wished,  prove  the  worry  and  annoyance  and  wear  and 
tear  on  their  endocrines  to  be,  as  it  really  is,  the  responsible 
factor  for  the  neurosis.  I  know  women  who  are  depressed 
and  unhappy  because  they  have  no  children.  I  know  women 
who  are  nervous  and  irritable  because  they  have  a  domineering, 
contrasuggestive,  or  unusually  self-assertive  husband.  I  know 
many  women  who  are  nervous  because  of  the  problems  asso- 
ciated with  the  training  and  care  of  their  children.  But  if  any 
or  all  of  these  have  dreams  at  one  time  or  another  of  a  sexual 
nature,  are  we  to  forget  all  the  innumerable  endocrine  plays 
on  instincts  and  emotions,  and  center  our  thought  on  the  sexual 
sphere,  even  though,  as  is  the  case,  the  sexual  sphere  is  likewise 
in  many  instances  responsible  for  neuroses  and  psychoses? 
And,  best  of  all,  when  we  explain  to  a  patient  that  she  or  her 
child  is  at  one  or  various  times  under  the  stimulation  of  the 
sex  hormones  of  the  numerous  endocrines  of  the  body,  and 
that  some  of  her  dreams  may  in  many  ways  be  the  end  result 
of  such  activity,  do  we  not  remove  from  such  patients  the 
fear  and  feeling  that  they  are  mere  animals,  unmoral  or  im- 
moral? And  if  we  are  correct  in  our  explanation  can  we  not 
prescribe  gland  extracts  which  inhibit  or  modify  this  over- 
activity?    We  can. 

When  a  person  Is  exhausted  by  normal  work  or  exercise 
and  sinks  Into  a  refreshing  sleep,  his  endocrines,  so  far  as  they 
are  associated  with  volitional  stimulation,  likewise  go  to  sleep, 
particularly  the  pituitary  and  thyroid.  If  an  individual  as  a 
result  of  reading,  mental  activity,  or  aroused  emotions  falls 
to  fall  asleep,  some  endocrine  activity  is  stimulating  those 
areas  and  functions  of  what  are  called  the  upper  consciousness, 
and  since  It  is  active,  It  continues  to  exert  control  over  the  sub- 
conscious.    A  thyroid  activity  stimulating  cerebral  action,  the 


THE  BALANCE   BETWEEN   THE   ENDOCRINES  309 

activity  of  any  other  endocrine  which  does  the  same  or  makes 
one  conscious  of  certain  emotions,  hkewise  stimulates  the  upper 
consciousness,  and  it  often  takes  people  hours  to  fall  asleep. 
Coffee  keeps  people  awake  since  it  stimulates  the  thyroid ; 
alcohol  may  do  the  same.  If  you  do  fall  asleep,  without  cere- 
bral and  endocrine  activity  previously  aroused  by  worries, 
anger,  fears,  joys,  unsatisfied  longings,  etc.,  and  the  upper 
consciousness  is  no  longer  stimulated,  the  subconscious  sphere 
may  likewise  be  inactive ;  you  sleep  well,  you  have  no  dreams, 
and  you  awaken  refreshed  because,  at  the  same  time  that  the 
upper  and  lower  spheres  of  consciousness  have  not  been  irri- 
tated into  activity,  the  sleeping  endocrines  have  been  exerting 
only  a  normal,  wholesome  effect  on  the  other  functions  of  the 
body  and  cell  repair  has  taken  place.  But  while  the  upper 
consciousness  is,  so  to  speak,  at  rest,  even  if  not  completely, 
and  you  are,  as  we  call  it,  asleep,  if  the  endocrines  exert  their 
play  on  what  we  call  the  subconscious  state,  you  have  all  va- 
rieties of  involuntary  recall,  and  since  volitional  control  is 
wholly  or  partly  absent,  the  activity  of  the  subconscious  may 
be  likened  to  the  saying  that  "While  the  cat's  away,  the  mice 
will  play." 

Let  us  make  a  comparison.  During  the  day  the  servants 
in  the  household  may  obey  your  orders  and  do  what  you  ask 
them.  When  once  their  work  is  over  their  behavior  below- 
stairs  is  like  the  action  of  the  subconscious  state.  You  may 
not  know  what  they  are  doing,  but  you  may  hear  something 
if  their  play  or  behavior  is  sufficiently  active  or  exuberant  to 
carry  sound  to  your  ears. 

Another  comparison.  An  officer  drilling  a  company  re- 
ceives prompt  response  to  his  orders.  If  he  and  his  com- 
pany retire  at  night  and  go  to  sleep  all  is  peaceful.  If  a 
hundred  men  be  given  leave  for  an  evening,  are  left  to  their 
own  resources,  there  may  be  a  hundred  different  forms  of  be- 
havior if  each  does  what  he  likes.  Several  groups  may  join 
in  different  diversions  or  all  may  do  the  same  thing  in  con- 
cert, but  they  certainly  will  not  drill  as  they  did  during  the 
day.    If  the  officer  is  away  he  knows  nothing  of  what  is  going 


310  THE   ENDOCRINES 

on.  If  he  is  with  them,  and  during  these  hours  he  attempts 
no  disciplinary  control  over  their  enjoyments  and  behavior, 
their  behavior  may  be  likened  to  the  action  of  the  subconscious 
state  while  the  upper  consciousness  is  out  of  action  so  far  as 
control  is  concerned.  These  comparisons  are  supposed  to  rep- 
resent the  various  types  of  dreams  resulting  from  endocrine 
stimulation  of  the  subconscious  sphere  by  endocrines  still 
awake.  While  any  endocrine  is  exerting  its  action  on  the  sub- 
conscious, of  course  it  may  also  be  acting  on  the  upper  con- 
sciousness, thus  calHng  its  attention  to  what  is  going  on  below, 
and  this  is  called  a  dream.  And  as  the  various  endocrines  are 
associated  and  brought  into  action  by  different  instincts  and 
emotions,  some  purely  mental,  some  those  of  anger  and  fear, 
some  sexual,  etc.,  the  reverse  action  or  recall  will  be  along  the 
lines  of  the  mental,  fearful,  sexual,  etc.,  according  to  the  en- 
docrine element  or  elements  which  are  acting  at  the  time  of 
the  dreaming. 

When  you  give  bromide  to  a  patient  you  are  diminishing 
the  sensitiveness  of  the  paths,  the  endocrines,  and  the  cerebral 
centers.  When  veronal  makes  a  patient  sleep  it  does  so  be- 
cause it,  so  to  speak,  puts  the  endocrines  (very  frequently  the 
thyroid  and  pituitary),  which  are  stimulating  the  upper  con- 
sciousness, into  a  state  of  diminished  activity.  Therefore, 
veronal  in  very  small  doses  is  an  excellent  drug  for  hyper- 
thyroidism. 

When  a  patient  after  several  hours  of  sleep  awakes  and 
cannot  fall  asleep  again,  some  endocrine  is  responsible  for 
the  rousing  of  the  upper  consciousness,  and  if  we  find,  by 
questioning,  the  nature  of  the  dream  which  aroused  the  patient, 
or  the  thought  or  emotion  which  is  now  present  during  this 
waking  state,  wecan  readily  discover  which  of  the  endocrines 
are  hyperactive  at  this  time.  Pain  arouses  by  messages  to  the 
cerebrum.  Some  day  when  we  have  analyzed  the  exact 
physiological  action  of  the  various  hypnotics  and  soporifics  we 
shall  prescribe  more  intelligently  for  sleeplessness  unless,  as 
is  probable,  endocrine  therapy  will  accomplish  this  result  better. 


THE  BALANCE  BETWEEN   THE   ENDOCRINES  311 

In  pregnancy  many  patients  suffer  from  nausea  and 
vomiting.  Those  who  do  not  suffer  in  this  way  are,  as  a  rule, 
rather  drowsy  or  sleepy.  In  the  former  there  is  a  rousing  of 
the  adrenals,  the  posterior  pituitary,  and  the  thyoid.  In  the 
latter  there  is  a  relative  diminution  of  activity  of  the  endocrine 
glands,  especially  the  hypophysis,  and  we  have  the  mildest 
form  of  hibernation  produced  by  the  action  of  placental  secre- 
tion on  the  posterior  pituitary.  If  you  administer  only  a  few 
drops  of  chloroform  to  a  patient  in  labor  after  the  injection  of 
pituitrin,  the  uterine  contractions  become  less  severe  and  recur 
at  greater  intervals.  Therefore,  chloroform  inhibits  the  pos- 
terior pituitary  or  its  action.  Castor  oil  and  quinine  have  a 
tendency  to  bring  on  labor  pains  if  administered  about  the  ex- 
pected time  of  labor.  Therefore,  they  either  act  directly  on 
the  uterus  or  stimulate  the  posterior  pituitary,  or  sensitize  the 
uterus  to  the  contractile  influence  of  pituitary  secretion.  Mor- 
phine puts  most  patients  to  sleep,  but  it  stimulates  some  and 
keeps  them  awake.  Therefore  in  the  former  it  acts  on  the 
upper  consciousness  and  on  the  endocrine  activity,  and  in  the 
latter  it  stimulates  both.  Drug  sleep  is  the  result  of  the  arti- 
ficial hibernation  produced,  whereas  normal  sleep  is  normal 
hibernation  or  normal  endocrine  rest.  The  endocrines,  so  to 
speak,  go  to  sleep.  Alcohol  keeps  some  patients  awake  and 
in  very  small  doses  it  puts  others  to  sleep.  Alcohol  given  in 
varying  degrees  up  to  intoxication,  removes  the  control  ex- 
erted by  the  upper  consciousness  and  the  anterior  pituitary, 
and  brings  out  evidences  of  the  instincts  and  emotions  in  dif- 
ferent individuals  according  to  the  endocrines  most  stimulated, 
and  we  may  have  an  individual  fearful,  tearful,  joyful,  pug- 
nacious, quarrelsome,  amorous,  etc. 

I  have  used  ovarian  extract,  whole  gland,  always  and 
rarely  corpus  luteum  extract.  Corpus  luteum  extract  counter- 
acts the  influence  exerted  by  whole  ovary,  for  in  the  latter  the 
interstitial  part  (ovarian  residue)  is  of  greatest  importance.  It 
is  the  glandular  part  and  the  corpus  luteum  which  stimulates 
the  adrenal  medulla  and  the  glandular  thyroid  which  are  the 
two  gland  structures  most  affected  in  hyperthyroidism  and  the 


312  THE    ENDOCRINES 

nervous  and  anxiety  states  of  women.  The  interstitial  thyroid 
and  the  adrenal  cortex  are  of  the  greatest  importance  and  these 
two  special  extracts  will  soon  be  in  our  hands.  Hence  I  have 
used  the  whole  suprarenal  gland  to  get  the  effect  of  the  cortex 
and  have  used  testicular  extract  as  an  added  help  where 
adrenal  cortex  action  was  desired.  I  am  now  paying  attention 
to  the  parathyroids  whose  importance  is  certainly  very  great. 
The  question  of  the  pineal  is  difficult,  but  some  of  my  cases 
with  suggestion  of  the  Mongolian  eyes  and  face  with  or  with- 
out obesity  are  being  watched  along  these  lines.  The  same 
balance  or  question  of  balance  as  exists  in  the  endocrines  above 
mentioned  exists  within  the  thyroid,  the  pancreas,  the  kidneys, 
in  the  muscles  and  bones,  in  the  brain,  and  in  all  the  structures 
of  the  body.  As  I  observe,  in  cases  now  being  studied,  kidney 
diseases  are  the  result  of  endocrine  abnormality.  Goodhart 
and  others  have  made  important  observations  in  muscular 
dystrophies.  If  we  apply  to  muscles  the  question  of  balance 
between  the  muscle  bundles  on  the  one  hand  and  the  connective 
and  elastic  tissue  fibres  on  the  other  hand  we  see  that  the  same 
relation  holds  good  as  is  observed  in  fibrosis,  fibromata  and 
myomata  of  the  uterus.  The  same  relationship  holds  in  kidney 
diseases,  overgrowth  of  the  interstitial  tissue,  or  of  the  gland- 
ular portion  or  of  both.  As  to  tumors,  benign  and  malignant, 
they  are  all  due  to  endocrine  action.  We  shall  find  that  car- 
cinomata  are  due  to  different  endocrines  according  to  their  situ- 
ation: breast,  pylorus,  coecum,  sigmoid,  uterus,  etc.  The 
neuroses  and  phychoses  are  endocrine  as  to  cause.  In  a  subse- 
quent page  the  curative  action  of  placental  extract,  for  exam- 
ple, on  pituitary  psychoses  and  on  other  states  due  to  the  pitu- 
itary and  other  glands,  will  be  reported.  In  conclusion  let  me 
make  this  prophecy.  In  five  years  there  will  be  few  mental  de- 
fectives (new),  few  feebleminded  (new),  few  insane  (new), 
few  tumors  (new),  few  cancers  (new),  few  diabetes  (new), 
few  renal  diseases  (new),  and  so  on.  Since  they  are  due  to 
endocrine  aberrations  they  will  be  corrected  in  their  earliest 
stages  by  endocrines.  When  the  next  war  comes,  if  it  does  at 
all,  soldiers  before  going  over  the  top  will  not  be  given  alcohol : 


THE  BALANCE  BETWEEN   THE  ENDOCRINES  313 

they  will  be  given  endocrine  cocktails  and  the  adrenal  cortex 
will  be  an  important  ingredient.  And  if  the  world,  in  the  near 
future  administer  to  its  diplomats,  to  its  highest  officials,  to  its 
legislators,  and  to  its  people  the  proper  endocrines,  especially 
anterior  pituitary,  and  inhibits  the  adrenal  cortex  a  little  bit, 
there  may  be  no  more  wars. 

Woman  is  a  combination  of  glandular  ovary,  corpus 
luteum,  adrenal  medulla,  glandular  thyroid,  posterior  pituitary, 
and  mammary  acting  much  more  energetically  and  specifically 
than  in  man.  That  is  why  they  have  hyperthyroidism,  pitui- 
tary conditions,  and  the  numerous  emotional  conditions  which 
we  have  so  long  and  so  erroneously  labelled  "neurasthenia," 
"hysteria,"  when  they  really  are  "neuroses,"  "psychoses."  And 
if  we  finally  conclude,  as  is  probable,  that  one  part  of  a  gland 
acts  through  the  vagus,  and  the  other  part  through  the  sym- 
pathetic, then  the  question  of  balance  is  of  greatest  importance. 

Many  of  the  statements  above  made  cannot  as  yet  be  sub- 
stantiated by  laboratory  investigation.  The}'  have,  however, 
stood  the  more  convincing  test  of  therapeutic  application. 


CHAPTER  -XIX 

THERAPEUTIC  SUGGESTIONS  CONCERNING 

ENDOCRINES 

The  human  body  is  managed  by  the  endocrine  glands  of 
the  body.  You  have  an  automobile,  and  it  is  run  by  gasoline 
of  one  kind.  In  spite  of  the  fact  that  it  has  a  competent  mech- 
anism, if  you  are  short  of  gasoline,  or  have  a  poor  quality  of 
gasoline,  that  invalidates  the  value  of  the  automobile.  But 
in  the  human  body  you  have  many  kinds  of  gasoline  given  off 
by  many  glands,  each  gland  producing  many  secretory  ele- 
ments. The  particular  division  of  these  secretions  we  do  not 
fully  understand,  but  each  gland  and  its  special  components  has 
a  definite  specific  action ;  and  every  individual  from  the  time  he 
is  born  until  the  time  he  dies  is  under  the  influence  of  these 
many  different  kinds  of  elements — some  of  them  having  to 
do  with  the  development  of  the  bones  and  teeth,  some  with  the 
development  of  the  body  and  nervous  system,  some  with  the 
development  of  the  mind,  etc.,  and,  later  on — with  the  intro- 
duction of  sex  features — with  reproduction.  Still  later  on, 
these  elements  have  to  do  with  the  preservation  of  these  struc- 
tures and  functions  which  constitute  the  body  and  mind,  and 
if  the  gasoline  elements  which  are  given  off  these  glands  be- 
come under-  or  over-active  there  is  a  disturbance  of  the 
specific  functions  which  these  component  parts  are  supposed 
to  perform;  and  since  these  glands  are  dependent  on  each 
other,  the  upset  of  one  disturbs  the  rhythmical  action  of  the 
others;  so  that  accordingly  a  woman  during  her  development 
and  maturity  keeps  in  action  as  her  glands  keep  in  normal 
action;  and  as  she  approaches  the  climacterium  and,  later  on, 
the  years  of  senility,  her  glands  change  and  her  activities 
change,  so  that  if  she  lives  long  enough  she  is  pretty  nearly 
back  to  where  her  body  functions  started  in  the  early  years. 

In  recent  years  our  knowledge  as  to  the  physiology  of 
the  ductless  glands  has  been  put  to  the  test  by  endocrine  ther- 
apy, and  there  is  no  longer  any  doubt  that  the  future  of  medi- 

314 


THERAPEUTIC  SUGGESTIONS  CONCERNING  ENDOCRINES     315 

cine  lies  along  these  lines.  In  my  own  practice,  endocrine 
therapy  has  displaced  and  replaced  the  old  time  drugs,  so  that 
I  might  safely  say  that  practically  90  per  cent,  of  all  my  pre- 
scriptions for  internal  use  consist  almost  entirely,  if  not  wholly, 
of  endocrine  extracts.  The  varying  forms  of  amenorrhea,  most 
of  the  menorrhagias  and  metrorrhagias,  threatened  miscar- 
riage, habitual  miscarriage,  sterility,  the  disorders  and  dis- 
turbances of  the  climacterium,  and  many  other  states  met  with 
in  gynecological  practice  may  be  corrected  in  many  instances 
specifically  by  a  certain  extract;  in  many  other  cases,  by  a 
combination  of  extracts. 

We  know  what  many  of  the  gland  extracts  will  do,  but 
we  have  not  yet  solved  the  question  as  to  how  many  various 
elements  enter  into  the  secretions  produced  by  any  of  these 
glands.  We  know  the  difference  between  the  adrenal  medulla 
and  the  cortex,  between  the  anterior  and  posterior  lobes  of  the 
pituitary,  between  the  interstitial  secretion  of  the  ovary  and 
that  of  the  follicle  apparatus,  and  in  all  probability  will  some 
iday  find  the  following  explanation :  Many  of  these  internal 
glands  secrete  more  than  one  element,  each  of  these  elements 
lacting  directly  on  certain  structures,  or  nerves,  or  nerve  ends, 
land  having  definite  stimulating,  trophic,  or  inhibiting  func- 
tions. On  the  other  hand,  such  of  the  gland  elements  as  w^e 
;know  have  a  varying  selective  action  according  as  they  act  on 
the  bones,  or  the  muscles,  or  the  mucous  membranes,  or  the 
musculature  of  the  hollow  viscera,  or  on  certain  nerves,  or  on 
the  branches  of  certain  nerves,  or  on  the  nerve  ends.  With 
either  of  these  ideas  in  mind  it  is  easy  to  picture  all  of  the 
functions  of  the  body  carried  out  by  the  proper  relation  be- 
tween stimulation  and  inhibition. 

The  selective  activity  of  the  endocrine  products  is  easy  to 
understand.  Pathology  has  taught  us  much  that  leads  to  a 
proper  understanding  of  physiology.  In  anterior  poliomyelitis 
there  is  a  selective  action  by  the  toxins  on  certain  cells  in  the 
anterior  horns ;  in  locomotor  ataxia  there  is  a  selective  action 
of  the  toxin  on  the  posterior  column  of  the  spinal  cord ;  in 
shingles,  some  toxin  acts  on  definite  nerve  roots.     Hence  it  is 


316  THE    ENDOCRINES 

no  stretch  of  the  imagination  to  conclude  that  nature  has  con- 
ferred on  the  ductless  glands  of  the  human  body  control  over 
practically  all  its  functions  by  giving  to  certain  elements 
definite,  specific  activities. 

Whatever  sequelse  and  complications  the  internist  may 
find  in  influenza  at  the  present  time,  the  gynecologist  and 
obstetrician  has  his  attention  fixed  very  decidedly  on  the 
endometrium,  whether  the  patient  is  pregnant  or  not.  I  have 
had  several  patients,  not  pregnant,  whose  menstruation  came 
on  early  and  excessively  shortly  after  an  attack  of  influenza. 
Several  pregnant  patients  have  spotted  and  stained  after  slight 
attacks  of  influenza.  One  patient  miscarried  in  the  fifth  month 
after  a  pneumonia;  and  another,  after  a  slight  attack  with  no 
pneumonic  process. 

The  endometrium  is  a  lymphoid  tissue,  and  I  have  come  to 
the  conclusion  that  the  uterine  mucosa  by  its  sensitiveness  to 
the  influenza  toxin  proves  that  the  disease  affects  markedly 
the  thymico-lymphatic  system,  and  that  when  this  barrier  is 
passed  the  toxins  act  most  disastrously  on  the  pituitary  and 
adrenal  structures;  so  that  the  specialist  in  diseases  of  women 
may  readily  come  to  the  conclusion  that  the  influenza  toxin — 
from  his  standpoint,  at  least — has,  if  not  a  selective  action  on 
the  endometrium,  at  least  a  predilection  in  that  direction. 

Trophic  control  over  development  and  growth,  and  the 
maintenance  of  the  normal  state  in  the  various  structures  of 
the  body  is  vested  in  the  ductless  glands,  and  immunity  or  lack 
of  immunity  to  various  diseases  is  more  than  probably  one  of 
the  most  direct  evidences  of  their  important  functions.  Nor- 
mal relation  of  these  gland  elements,  whether  their  action  is 
exerted  directly  on  the  tissues  in  question  or  upon  the  struc- 
tures through  the  medium  of  the  nerves  and  nerve  ends,  pre- 
serves a  proper  state  of  growth;  and  the  lack  of  trophic  care 
or  an  overstimulation  of  tissue  cells  and  epithelial  cells  must 
lead  to  abnormal  growth.  In  this  view  of  the  question,  I  be- 
lieve will  eventually  be  found  the  cause  of  benign  and  malig- 
nant growths  of  the  body. 


THERAPEUTIC  SUGGESTIONS  CONCERNING  ENDOCRINES    317 

Dermoid  cysts  represent  the  growth  of  embryonic  ele- 
ments displaced  in  clefts  during  the  development  of  the  embryo, 
or  of  such  elements — located,  for  instance,  in  the  ovary — 
which  at  first  dormant,  are  not  inhibited  and  are  at  some  period 
stimulated  to  growth.  That  many  of  these  cells  have  lain 
dormant  for  years  and  have  then  taken  on  a  growth,  proves 
the  question  to  be  either  lack  of  inhibitory  control  or  more 
probably  overstimulation. 

Chorioepithelioma  is,  after  all,  the  very  best  evidence  of 
lack  of  inhibition  or  overstimulation  in  the  mother  afflicted 
with  this  condition.  Certain  cells  of  the  ovum's  outer  layer 
have  been  retained  in  a  uterus  after  a  miscarriage  or  a  full-term 
pregnancy,  and  after  a  few  months,  or  even  after  two  or  three 
years,  these  develop  into  a  malignant  growth  characterized  by 
metastatic  deposits  carried  through  the  blood  channel.  It  is 
perfectly  evident  that  these  cells  have  grown  either  because  a 
protective  ferment  or  element  is  lacking  in  the  individual  in 
whose  uterus  these  cells  have  developed  the  above  mentioned 
growths  or  because  an  overstimulation  exists  which  forces 
these  cells  and  fosters  their  growth. 

The  uterus  of  every  woman  is  the  potential  carrier  of 
myoma  or  fibroma.  If  she  bears  children  and  the  uterus  is 
engaged  in  carrying  out  the  functions  for  which  it  is  prepared 
by  the  action  of  the  ovary,  thyroid,  pituitary,  and  other  glands, 
there  is  certainly  less  likelihood  of  fibroma  or  myoma  develop- 
ing through  hyperpituitarism  than  if  she  have  no  children. 

For  instance,  we  have  the  pituitary  gland,  especially  the 
posterior  lobe,  which  is  often  hypoactive.  We  know  that  a 
woman  grows  stout,  menstruates  less  and  less,  and  has  an 
atrophy  of  the  uterus  and  ovaries,  often  permanent,  when  the 
posterior  lobe  underacts  markedly  for  a  long  period  of  time, 
this  condition  being  called  dystrophia  adiposogenitalis.  There- 
fore, on  the  basis  of  both  theory  and  practice,  we  know  what 
hyperactivity  of  this  lobe  should  produce.  It  overstimulates 
both  ovary  and  uterus,  and  in  all  probability  is  the  cause  of 
fibromata  and  myomata  of  the  uterus  and  of  the  condition 
known  as  fibrosis  uteri,  in  which  condition,  at  operation,  the 


318  THE    ENDOCRINES 

ovaries  are  found  large  and  hyperplastic  and  certainly  are 
overactive. 

There  are  so  many  manifestations  of  hyperpituitarism 
that  are  probable  but  not  yet  definitely  settled,  that  it  may  seem 
almost  theoretical  to  mention  some  of  these  states.  For  -in- 
stance, many  cases  of  dysmenorrhea  are  cases  of  hyperactivity 
of  the  pituitary  lobe  at  the  menstrual  crisis.  Again,  I  recently 
operated  on  a  patient  suffering  from  what  w^as  diagnosed  as 
prolapse  of  the  uterus,  the  cervix  appearing  at  the  vulva.  She 
had  had  no  children,  in  fact,  was  unmarried.  I  diagnosed  it 
as  a  case  of  elongatio  colli,  with  retroflexed  uterus.  The  uterus 
was  more  than  twice  the  normal  length.  I  amputated  the 
cervix  at  the  level  of  the  internal  os,  and  the  amputated  cervix 
was  certainly  over  three  inches  long.  In  talking  on  this  case 
during  this  step  of  the  operation,  I  stated  that  this  condition, 
as  well  as  fibroids  and  fibrosis  of  the  uterus,  was  an  evidence 
of  some  hyperactivity  of  the  posterior  lobe.  When  I  opened 
this  patient's  abdomen  in  order  to  correct  the  retroflexion,  I 
found  a  large  uterus  with  a  fibroid  the  size  of  a  walnut  on  the 
fundus.  This,  of  course,  might  have  been,  unless  my  theory  is 
right,  simply  a  coincidence,  but  I  believe  the  above  expressed 
view  to  be  the  correct  one.  I  have  recently  had  a  parallel  case 
in  a  married  but  multiparous  patient.  The  elongation  of  the 
cervix  was  nearly  four  inches.  She  had  a  very  large  subperi- 
toneal fibroid.  Her  general  symptoms  are  those  of  posterior 
pituitary  plus. 

I  wonder  if  the  following  case  is  to  be  viewed  as  merely 
a  coincidence :  Patient,  married  six  years,  2-para,  menstruates 
every  twenty-eight  days,  duration  four  to  seven  days,  large  in 
amount.  Her  premenstrual  phenomena  are  sleeplessness  and 
frequency  of  bowel  movements,  which  have  become  more 
marked  in  the  last  year.  Her  blood  pressure  was  140,  and  my 
diagnosis  was  hyperpituitarism,  combined  possibly  with  hypo- 
thyroidism. In  asking  her  whether  she  had  nursed  her  second 
baby,  born  two  years  ago,  she  replied,  no,  because  the  baby 
had  suffered  from  pyloric  spasm  and  had  been  operated  upon 
for  the  same.     If  the  whole  question  of  heredity  is,  as  I  be- 


THERAPEUTIC  SUGGESTIONS  CONCERNING  ENDOCRINES    319 

lieve,  mainly  a  matter  of  inheritance  of  endocrine  relationship, 
then  this  hyperpituitarism  in  the  mother  and  pyloric  spasm  is 
more  than  simple  coincidence. 

We  know  that  the  history  of  a  patient's  premenstrual 
phenomena  constitutes  one  of  the  most  important  diagnostic 
aids  in  all  gynecology,  for  at  this  period,  which  is  a  crisis,  inter- 
glandular  malrelations  are  brought  into  the  foreground.  Many 
patients  suffer  from  marked  headaches  at  and  during  this 
period ;  others  suffer  from  nausea  and  vomiting,  and  these  un- 
doubtedly represent  overactivity  on  the  part  of  related  glands, 
among  which  the  pituitary  is  often  overactive  at  menstruation. 

When  a  patient  is  pregnant  and  the  menstrual  activities 
of  the  ovary,  thyroid,  and  pituitary  are  nullified  and  held  in 
check  by  the  placental  secretion,  we  have  a  constant  struggle 
between  these  two — secretions  of  the  mother  and  the  secretion 
of  the  ovum — during  the  entire  270  odd  days  of  pregnancy. 
If  the  placental  secretion  cannot  hold  the  maternal  secretions 
in  check,  the  latter  assert  themselves  and  the  patient  has  a 
miscarriage.  This  is  the  explanation  of  repeated,  habitual 
miscarriages,  and  hyperpituitarism,  posterior  lobe,  plays  an 
important  part  in  this  condition. 

Many  pregnant  patients  are  not  nauseated  at  any  time 
while  they  are  carrying  an  ovum  in  utero;  others  are  nauseated 
in  varying  degrees.  I  have  frequently  noted  that  many 
patients  who  are  not  nauseated  are  quite  drowsy  and  sleepy.  I 
am  accustomed  to  tell  such  sleepy  patients  that  this  is  a  favor- 
able sign,  as  nausea  is  not  a  probable  annoyance  from  which 
they  will  suffer.  This  nausea  and  vomiting  represents  a  reac- 
tion on  the  part  of  the  system  to  the  introduction  of  the 
placental  secretion.  If  a  stable  adjustment  results  quickly,  the 
nausea  disappears  quickly.  In  this  readjustment,  undoubtedly 
(in  the  cases  which  vomit  and  vomit  decidedly),  we  are  con- 
cerned either  with  a  toxic  influence  produced  by  the  placental 
extract  or  with  an  exaggerated  reaction  on  the  part  of  the 
posterior  lobe,  with  resulting  hypersensitiveness  of  the  gastro- 
intestinal tract.  How  great  a  part  transient  forms  of  pyloric 
spasm  play  in  this  persistent  nausea  and  vomiting  remains  to 


320  THE    ENDOCRINES 

be  decided.  Those  patients  who  are  sleepy  and  drowsy  (and 
these  are  not  nauseated  nor  do  they  vomit)  have  the  opposite 
condition — an  underactivity  of  the  posterior  pituitary  lobe. 

I  have  formerly  considered  fibrosis  to  be  due  to  hyperactiv- 
ity of  the  ovaries.  Now  that  we  know  the  special  relation  of^ 
the  pituitary  to  the  ovary  and  the  uterus,  we  realize  that  at  the 
menopause  period,  when  gland  activity  as  it  relates  to  the  sex- 
structure  should  diminish,  the  pituitary  gland  may,  on  the  con- 
trary, remain  active  or  hyperactive.  This  will  give  at  the 
menopause  period  ovaries  which  do  not  regress,  a  uterus 
which  is  overstimulated,  with  the  result  that  the  patient  has  a 
menorrhagia  or  metrorrhagia,  a  large  uterus,  and  large  ovaries 
at  a  time  when  atrophy  should  be  in  view.  Therefore,  the 
study  of  any  change  occurring  in  a  patient  at  the  climacteric 
period  (many  of  these  changes  begin  years  before  the  meno- 
pause comes  on)  must  concern  itself  with  the  question  of  re- 
gression. If  ovary,  thyroid,  adrenals,  and  pituitary  gland 
diminish  in  activity  harmoniously  and  in  the  same  ratio,  the 
patient  develops  amenorrhea,  atrophy  of  the  genitalia,  with  no 
symptoms  of  hyperpituitarism,  or  hyperthyroidism,  hyper- 
adrenalism,  or  hyperovarianism.  If  ovarian  regression  is  too 
rapid  for  the  body  needs,  we  have  flushes,  due  to  sudden  loss 
of  ovarian  stimulus,  and  to  continued  posterior  pituitary  activ- 
ity; we  may  observe  hypothyroidism,-  if  the  same  condition 
takes  place  previously  in  the  thyroid ;  or  hypopituitarism,  if  the 
hypophysis  shows  the  same  rapid  decline.  The  reverse,  that 
is,  overactivity,  in  one  or  other  of  the  glands  is  just  as  fre- 
quent, if  not  more  so,  in  the  cases  seen  by  the  gynecologist. 

When  we  consider  that  one  or  other  of  these  glands,  not 
forgetting  the  adrenals  and  other  secretory  structures,  may 
regress  much  more  quickly  or  more  slowly  than  the  others ; 
and  that  various  combinations  of  these  processes  may  take 
place,  we  see  that  we  may  have  in  any  patient  various  combi- 
nations of  hypearactivity  or  hypoactivity  which  need  not  be 
permanent  but  which  may  change  and  fluctuate  at  this  period, 
so  characterized  by  instability  that  the  laity  have  well  named 
it  "change  of  life."    It  is  no  rare  thing  to  see  a  patient  during 


THERAPEUTIC  SUGGESTIONS  CONCERNING  ENDOCRINES    321 

or  after  the  menopause  suffering  from  alternating  hyperthy- 
roidism and  hypothyroidism,  and  the  same  is  true  concerning 
the  pituitary  and  the  ovary,  and  in  the  pituitary  we  have  the 
basic  element  of  high  blood  pressure  if  the  thyroid  be  minus. 

In  the  condition,  to  which  we  have  already  referred, 
known  as  dystrophia  adiposogenitalis,  the  patients  are  very 
sugar-tolerant  and  may  be  given  large  amounts  of  glucose 
without  sugar  appearing  in  the  urine.  By  theory  and  by 
observation,  it  must  of  necessity  be  concluded  that  overactivity 
of  this  lobe  will  make  the  patients  very  slightly  tolerant  of 
sugar,  and  this  is  undoubtedly  one  of  the  important  causes  of 
glycosuria.  We  know  the  relation  of  the  pancreas  to  glyco- 
suria, but  we  have  not,  in  therapy,  at  least,  given  sufficient 
attention  to  the  relation  which  the  ovaries,  and  more  especially 
the  thyroid,  the  adrenals,  and  the  pituitary,  bear  either  to  the 
pancreas  directly  or  to  the  sugar-forming  or  sugar-retaining 
qualities  of  the  body.  Therefore  many  patients  with  fibromata 
and  myomata  have  glycosuria,  many  of  them  have  tachycar- 
dia, which  means  either  a  coincident  involvement  of  the  thy- 
roid or  adrenals  or  tachycardia  from  hyperpituitarism  in- 
directly. 

Whether  this  overactivity  of  the  pituitary  has  anything 
to  do  with  gallstones,  I  do  not  know.  I  believe  this  to  be  the 
case.  We  do,  however,  observe  frequent  association  between 
fibromata  of  the  uterus,  the  postpartum  period,  and  stones  in 
the  gall-bladder. 

In  gland  therapy  we  must  realize  that  it  is  easy  to  admin- 
ister the  extracts  when  any  gland  fails  in  action.  We  simply 
supply  what  is  needed.  The  more  difficult  and  eventually 
glorious  part  is  to  overcome  the  hyperaction  of  any  gland ;  and 
this  must  be  done  by  selecting  those  other  extracts  which 
counteract  or  antagonize  this  activity. 

In  searching  for  endocrine  elements  that  are  antagonistic 
to  the  posterior  pituitary  lobe,  we  may  take  these  three  points 
into  consideration.  Mammary  gland  function  and  mammary 
gland  extract  certainly  have  the  effect  of  diminishing  menstru- 
ation,  contracting  the  uterus,   shrinking  fibromyomata,    and 


322  THE    ENDOCRINES 

limiting  the  activity  of  the  ovaries.  We  must  presume  that  it 
may  have  the  same  effect  upon  the  posterior  pituitary  lobe. 

The  thymus  has  the  effect  of  controlling  the  activity  of 
the  gonads  until  the  developmental  age  comes  on,  after  which 
the  thymus  is  supposed  to  regress  and  allow  the  sex  arrange- 
ments to  develop.  We  know,  then,  that  thymus  extract,  if 
given  therapeutically,  will  in  certain  cases  diminish  menor- 
rhagia  and  metrorrhagia  through  action  on  the  ovaries,  and 
that  thymus  extract  has  value  in  quieting  sex  sensations.  It 
may  have  an  effect  on  the  posterior  pituitary  lobe. 

When  a  woman  is  pregnant,  the  placental  secretion  in- 
hibits the  menstrual  activity  of  the  ovary,  of  the  thyroid  and 
the  posterior  pituitary  lobe.  Therefore  we  may  have  in 
placental  extract  a  secretion  that  has  some  controlling  influence 
over  the  posterior  pituitary  lobe.  If  this  be  so,  it  should  help 
us  in  the  treatment  of  dysmenorrhea  due  to  posterior  lobe  hy- 
peractivity, and  should  help  us  in  those  cases  of  glycosuria  due 
to  the  hyperactivity  of  the  posterior  hypophysis  gland.  I  have 
helped,  not  cured,  many  patients  suffering  from  dysmenorrhea, 
by  giving  placental  gland  extract  by  mouth  and  by  hypodermic. 
I  have  had  remarkable  results  in  several  cases  of  glycosuria 
at  the  climacterium,  seeing  the  urine  clear  up  and  the  sugar  dis- 
appear by  the  administration  of  placental  gland  extract,  with 
very  little  restriction  of  the  diet. 

We  may  then  conclude  that  certain  forms  of  glycosuria, 
if  they  be  dependent  on  pituitary  lobe  hyperactivity,  should 
react  and  improve  if  placental  extract  be  given. 

If  the  mammary  gland  and  the  thymus,  in  addition  to  act- 
ing on  the  uterus  and  the  ovary,  also  inhibit  the  posterior  lobe, 
they  should  be  tried,  if  not  in  other  forms  of  glycosuria,  at 
least  in  the  form  of  which  I  have  just  spoken.  How  many 
cases  of  hypertension  or  increased  or  raised  blood  pressure, 
especially  those  noted  in  women  at  the  menopause  or  subse- 
quently, are  due  to  hyperactivity  of  the  posterior  pituitary  lobe 
remains  to  be  decided.  Judging  from  therapeutic  results  thy- 
roid minus  and  posterior  pituitary  plus  form  the  most  frequent 
endocrine  cause  of  high  blood  pressure.     At  this  menopause 


THERAPEUTIC  SUGGESTIONS  CONCERNING  ENDOCRINES    323 

or  climacteric  period,  when  the  activity  of  the  ovaries  is  sup- 
posed to  diminish,  when  there  should  be  and  often  Is  regression 
in  activity  on  the  part  of  the  thyroid,  we  expect  that  the  pos- 
terior lobe  will  regress  too,  since  the  patient's  sex  activity  is 
no  longer  of  importance.  This  regression,  however,  often 
fails  to  take  place. 

My  purpose  in  setting  down  these  views  is  to  direct  at- 
tention to  the  possible  value  of  thymus  extract,  mammary  ex- 
tract, and  especially  placental  extract  in  those  conditions  due 
to  hyperpituitarism,  among  which  are  certain  cases  of  gly- 
cosuria, many  cases  of  high  blood  pressure  and  many  abnor- 
mal psychic  states  and  many  psychoses. 

The  influence  and  activity  of  the  endocrine  glands  are 
evidenced  by  the  stimuli  and  the  changes  produced  on  the  body, 
on  metabolism,  on  the  nervous  system,  on  blood  pressure,  and 
on  the  psyche.  In  some  instances  abnormalities  of  gland  ac- 
tivity are  characterized  by  physical  stigmata ;  in  others,  by 
changes  in  the  activity  of  organs  whose  function  is  continually 
under  the  influence  of  the  nervous  system;  in  still  other  indi- 
viduals, abnormalities  of  gland  activity  are  evidenced  by 
changes  in  the  psyche;  and  in  some,  combinations  of  various 
forms  are  in  evidence, 

OvARiN. — It  seems  strange  that  after  all  the  tremendous 
amount  of  experimental  work  which  has  been  done,  and  after 
all  of  the  verification  which  physiologic  and  pathologic  investi- 
gations have  given  in  the  pursuit  of  this  topic,  there  should 
still  be  physicians  who  doubt  the  existence  of  an  ovarian  se- 
cretion. They  readily  grant  the  tremendous  importance  of  the 
thyroid  and  the  suprarenal  structures,  and  are  now  beginning  to 
recognize  the  important  role  of  the  hypophysis.  Recognition 
of  the  importance  of  the  thyroid  and  adrenal  apparatus  was 
probably  furthered  by  the  therapeutic  results  obtained  by  the 
secretions  of  these  glands,  used  experimentally  or  medically.. 
The  fact  that  up  to  date  no  ovarian  secretion  has  been  mar- 
keted, which  produces  in  the  same  short  space  of  time  marked 
or  noticeable  efifects,  possibly  accounts  in  a  measure  for  the 
failure  to  grant  to  the  ovaries  the  place  they  deserve  as  most 


324  THE    ENDOCRINES 

important  factors  in  the  female  economy,  aside  from  their  very 
important  function  of  producing  ova.  At  almost  all  periods  of 
life  the  thyroid,  the  pituitary,  and  the  suprarenals  especially, 
are  intimately  concerned  with  the  vital  daily  processes  to  a 
greater  or  lesser  degree.  Whereas  the  ovary  exerts  its  influ- 
ence over  a  very  extended  period  of  time  in  channels  and  ways 
which  show  no  decided  alterations,  but  only  gradual  but  last- 
ing phenomena,  it  must  be  granted  by  everyone  that  removal 
of  the  ovaries  in  young  animals  or  young  human  beings  stops 
complete  development  of  the  mammary  gland  and  the  exter- 
nal and  internal  genitalia,  especially  the  uterus.  In  adult 
women,  removal  of  the  ovaries  is  followed  by  atrophy  of  the 
internal  genitalia,  most  particularly  the  uterus.  At  the  climac- 
terium regressive  changes  in  the  ovaries  are  followed  by  atro- 
phy of  the  genitalia.  These  factors  are  universally  known, 
and  they  are  generally  recognized  as  resulting  partly  through 
the  failure  of  a  secretion  produced  by  the  ovaries. 

The  ovary  has  a  remarkable  effect,  too,  in  influencing  the 
form  of  bony  growth  in  the  female.  It  produces  the  female 
type  of  pelvis ;  it  has  to  do  with  the  degree  and  extent  of  skel- 
etal growth.  It  is  intimately  concerned  with  the  changes  pro- 
duced in  osteomalacia.  It  has  an  intimate  relationship  with 
the  thyroid,  the  thymus,  the  adrenals,  and  the  hypophysis, 
glands  which  are  extremely  important  in  the  processes  of  bony 
growth  and  ossification.  The  alterations  produced  in  the  ovary 
in  acromegaly  are  so  decided  that,  in  the  minds  of  many  ob- 
servers, they  are  the  primary  factors  in  the  production  of  this 
disease.  The  same  holds  true  in  the  cases  of  giants  and  dwarfs. 
All  these,  and  innumerable  other  points,  which  I  have  previous- 
ly mentioned,  prove  the  great  importance  which  the  ovaries 
bear  in  the  general  economy ;  however,  to  be  sure,  scarcely  vital. 
The  most  important,  and,  in  my  mind,  extremely  important, 
relationship  in  women  exists  between  the  ovary,  the  pituitary, 
the  thyroid  and  adrenals.  ]\Iany  years  ago  my  attention  was 
attracted  in  this  direction  by  the  observation  that,  in  many  cases 
of  ovarian  hypofunction  in  young  women,  there  were  symp- 
toms of  a  digestive  and  general  nervous  nature  that  implied  a 


THERAPEUTIC  SUGGESTIONS  CONCERNING  ENDOCRINES    325 

toxic  irritation  by  some  other  secretion.  The  study  of  the 
changes  produced  at  puberty,  before  menstruation,  before  and 
during  the  cHmacterium,  taught  me  that  in  innumerable  cases 
we  were  deahng  with  actual  or  relative  hyperthyroidism,  and  I 
gave  to  that  class  of  patients,  in  whom  an  excess  of  thyroid 
was  due  to  hypofunction  of  the  normally  antagonizing  ovarian 
secretion,  the  name  of  relative  Basedow's  disease.  Many  of 
these  cases  manifested  their  annoyances  in  association  witli 
menstruation — that  is,  usually  in  the  premenstrual  phase — 
and  it  is  important  in  this  type,  of  what  might  be  called  con- 
stitutional dysmenorrhea,  to  distinguish  between  the  cases  due 
to  overactivity  of  the  corpus  luteum  secretion  itself,  due  to  it=> 
being  in  excess,  so  to  speak,  and  the  type  where  the  annoyances 
are  due  to  an  actual  excess  of  thyroid  secretion  and  the  type 
due  to  hyperpituitarism.  We  may  distinguish  three  types  :  ( 1 ) 
The  annoyances  are  due  to  too  much  corpus  luteum  secretion; 
(2)  there  is  normal  stimulation,  by  either  pituitary  or  thyroid 
secretion  in  a  patient  with  an  extremely  hypersensitive  or- 
ganism; (3)  there  is  real  hyperthyroidism  or  real  hyperpitui- 
tarism posterior. 

The  diagnosis  between  the  annoyances  due  to  excessive 
pituitary  stimulation  on  the  one  hand,  and  hyperthyroidism 
stimulated  by  the  corpus  luteum  secretion,  may  be  in  many  in- 
stances readily  made  by  the  use  of  ovarian  extract  and  of  thy- 
roid extract.  Any  patient  suffering  from  this  premenstrual  dys- 
menorrhea of  a  constitutional  type  due  to  hyperthyroidism  is 
made  distinctly  worse  by  the  use  of  thyroid  extract,  1/10  to  1/2 
grs.  three  times  a  day.  Any  patient  whose  premenstrual  annoy- 
ance is  due  to  the  presence  in  the  blood  of  an  excess  of  the 
pituitary  hormone  is  benefited  by  the  exhibition  of  thyroid  ex- 
tract. Annoyances  due  to  corpus  luteum  stimulation  are  bene- 
fited by  ovarian  extract  or  ovarian  residue.  In  this  type  of 
case,  and  in  cases  of  a  nervous  nature,  at  whatever  age  or 
stage,  I  have  for  years  made  use  of  the  thyroid  extract  for 
diagnostic  purposes,  and  have  unearthed  thereby  many  cases 
of  relative  and  actual  hyperthyroidism,  and  have  seen  several 
of  these  patients   subsequently   develop   distinct   signs   which 


326  THE   ENDOCRINES 

absolutely  verified  the  diagnosis.  In  my  experience,  ovarian 
extract  is  a  valuable  drug.  Lutein  extract  has  given  me  good 
results  in  menorrhagia,  but  the  indications  are  different.  I  find 
that  ovarian  extract  and  ovarian  residue  are  of  great  value  in 
the  minor  degrees  of  hyperthyroidism,  especially  the  forms 
depending  on  hypofunction  of  the  ovaries.  It  is  a  very  valu- 
able drug  in  lactation  atrophy  of  the  uterus.  It  has  given  me 
for  years  very  good  results  in  the  flashes  of  the  climacterium, 
especially  when  begun  early  and  combined  with  placental  ex- 
tract. If  begun  shortly  after  operation,  there  are  few  cases  of 
castration  who  suffer  very  much  from  the  so-called  flashes.  In 
the  few  cases  of  chlorosis  which  have  come  under  my  observa- 
tion, and  in  the  many  cases  of  anemia,  it  has  served  me  very 
well.  I  learned  many  years  ago  to  combine  iron  and  arsenic 
with  ovarian  extract  in  almost  every  indicated  case,  especially 
where  the  hemoglobin  was  reduced,  and,  on  the  other  hand, 
in  cases  of  anemia,  where  the  iron  was  the  primary  indica- 
tion, I  almost  invariably  added  ovarian  extract.  So  that  1 
have  adopted  for  myself  the  rule  when  you  give  iron  also 
give  ovarin;  when  you  give  ovarin  also  give  iron.  I  find 
that  each  accentuates  the  action  of  the  other.  In  amenorrhea, 
relative  or  absolute,  it  has  been  my  standby  for  years.  The 
type  in  which  least  influence  on  the  arnenorrhea  is  obtained  is 
the  precocious  menopause  of  obesity,  which  I  am  now  begin- 
ning to  consider  in  many  cases  as  a  dystrophia  adiposogenitalis, 
dependent  on  a  disturbance  in  which  hypophysis  minus  plays 
an  important  part.  Ovarian  extract  is  a  drug  which  must  be 
used  for  a  long  time,  and  one  which  must  be  judiciously  com- 
bined with  other  drugs.  It  produces  no  annoyances,  and  the 
main  contraindication  consists  of  profuse  bleedings.  I  have, 
in  many  instances,  combined  ovarian  extract  with  thyroid,  es- 
pecially to  promote  metabolism  and  encourage  oxidation.  The 
annoying  symptoms  produced  by  thyroid  extract  are  often  sur- 
prisingly diminished  by  adding  ovarian  extract.  For  thera- 
peutic purposes  I  have  learned  to  give  small  doses  of  thyroid 
extract,  1/10  to  1/6  gr.  three  times  a  day,  often  producing 


THERAPEUTIC  SUGGESTIONS  CONCERNING  ENDOCRINES    327 

splendid  results.     For  diagnostic  purposes  I  have  given  larger 
doses. 

Thyroid 

Thyroid  is  often  given  in  too  large  doses.  One  should 
rarely  begin  with  more  than  one-tenth  of  a  grain  three  times 
a  day.  And  one  grain  three  times  a  day  should  be  a  maximum 
dose,  and  then  only  after  several  weeks  in  pronounced 
myxedema.  Many  patients  can  only  stand  one-twentieth  of 
a  grain. 

In  rheumatism  and  allied  states  one-tenth  of  a  grain  three 
times  a  day  is  a  prophylactic  dose,  and  one-quarter  of  a  grain 
three  times  a  day  is  a  therapeutic  dose.  These  very  small  doses 
are  sometimes  of  value  in  chorea. 

Thyroid  is  valuable  in  certain  forms  of  menorrhagia  and 
in  renal  and  intestinal  hemorrhage. 

The  huge  number  of  cases  of  hyperthyroidism  are  tran- 
sient, and  recover  readily  with  appropriate  medication  and 
treatment.  Change  of  climate,  rest,  administration  of  various 
gland  extracts,  etc.,  are  of  value. 

The  milder  nervous  symptoms  include  excitability,  a 
change  of  habits,  and  taste.  There  may  be  glycosuria,  pig- 
mentation of  the  skin,  sweating,  and  vasomotor  instability  of 
the  skin.  There  may  be  a  fidgety  and  nervous  manner.  Pre- 
menstrual nervous  symptoms  are  the  rule,  especially  if  the 
post,  pituitary  is  overactive.  The  condition  is  generally  pluri- 
glandular. Hyperthyroidism  must  be  viewed  as  a  pluriglandu- 
lar condition,  involving  especially  the  adrenals,  the  pituitary 
and  the  ovaries  and  the  symptoms,  both  physical,  visceral,  meta- 
bolic and  psychic,  vary  for  that  reason.  The  thyroid  is  com- 
posed of  a  glandular  and  interstitial  tissue  and  symptoms  vary 
according  to  the  degree  to  which  these  are  involved. 

Physical  or  mental  strain  should  be  avoided.  Rest  in  bed 
for  a  few  weeks  is  advisable,  on  account  of  the  tachycardia  or 
muscular  weakness  or  the  nervous  irritability  and  the  other 
symptoms. 

The  various  emotions  rouse  the  thyroid  to  activity.  The 
same  is  true  of  the  sexual  sphere  and  of  the  various  diseases 


328  THE    ENDOCRINES 

of  the  genitalia.  Arsenic,  the  iodids,  coffee,  tea,  and  alcohol, 
and  the  salicylates  stimulate  the  thyroid. 

The  thyroid  is  quieted  by  rest  and  quiet,  freedom  from 
sexual  relations,  and  correction  of  pelvic  annoyances,  a  milk 
diet  and  glycerophosphates,  belladonna,  bromids,  and  especially 
opium  and  ergot. 

We  may  use  ovarin,  ovarian  residue,  extracts  of  the 
pituitary  gland,  thymus,  suprarenal,  placental  extract,  accord- 
ing to  the  indications  peculiar  to  each  case.  Thyroid  extract 
should  be  contraindicated.  Extract  of  suprarenal  gland  seems 
to  work  well  especially  when  combined  with  ovarian  extract  or 
ovarian  residue.  Ovarian  extract,  gr.  5,  three  times  a  day,  is 
very  valuable.     It  may  be  given  for  months  or  years. 

R.     Ext.  glandulas  suprarenalis §t.  ij 

Ovarian  extract   gr.  v 

S. — One  capsule  t.i.d. 

Sodium  phosphate,  one  teaspoonful  every  morning,  is 
also  very  good.  Sodium  glycerophosphate  is  very  valuable. 
Ergot  and  digitalis  aid  the  relaxed  heart. 

The  thyroid  is  stimulated  by  small  doses  of  iodin,  and  it 
also  stimulates  the  cerebrum  and  cerebration.  In  Basedow's 
disease  the  iodin  is  decreased  in  the  gland  and  is  in  excess  in 
the  blood.  Iodin  is  attracted  to  the  cells  of  the  thyroid.  In 
small  doses  it  has  a  tendency  to  stimulate  the  gland  and  cause 
absorption  of  retained  secretions.  The  specific  action  of  iodin 
in  goiter  (not  exophthalmic,  not  hyperthyroidism)  results  only 
if  functionating  gland  tissue  is  present,  and  hypertrophy  will 
recede  if  dependent  on  improper  function  or  retained  secre- 
tion. In  parenchymatous  goiter,  where  all  the  constituents  are 
enlarged,  a  potassium  iodid  ointment  is  often  efficient.  Potas- 
sium iodid  is  of  value  in  simple  goiter,  causing  it  often  to  dis- 
appear, but  it  usually  makes  Basedow's  disease  worse. 

Polyglandular  Combination. — "This  includes  patients 
showing  unmistakable  evidence  of  ductless  gland  disorders. 
In  acromegaly  there  is  a  frequent  co-existence  of  a  goiter. 
There    is    early    glycosuria,    amenorrhea,    pigmentation,    and 


THERAPEUTIC  SUGGESTIONS  CONCERNING  ENDOCRINES    329 

asthenia,  suggesting  affections  of  the  thyroid,  the  pancreatic 
islets,  the  ovary,  and  adrenals.  These  organs  are  all  involved, 
either  by  the  underlying  biochemic  disturbance  which  is  the 
background  for  many  ductless  gland  disorders,  or  else  they 
are  secondarily  implicated  during  the  compensatory  readjust- 
ment of  metabolic  processes  consequent  upon  the  primary  de- 
rangement of  the  gland  in  question.  A  primary  hypophyseal 
derangement  is  capable  of  bringing  about  a  functional  unset- 
tling of  the  entire  glandular  series"  (Gushing).     . 

"In  the  case  of  the  thyroid  and  parathyroids  the  pituitary 
and  pineal  bodies,  the  adrenals,  thymus,  pancreatic  islets,  testis 
and  ovary,  disturbances  of  function,  whether  in  the  direction 
of  increased  or  of  lessened  activity,  will  doubtless  occasion  re- 
ciprocal alterations  in  one  or  another  of  the  correlated  glands. 
Despite  the  ultimate  polyglandular  nature  of  the  picture  from 
the  pathologic  point  of  view,  a  primary  disturbance  of  each  one 
of  these  glands,  whether  in  the  direction  of  overactivity  or 
underactivity,  doubtless  will  be  found  to  possess  its  own  char- 
actistic  clinical  syndrome,  which  differs  from  that  of  each  of 
the  other  glands." 

"As  a  result  of  experimental  reproduction,  the  symptoms 
associated  with  primary  glandular  insufficiency  are  the  better 
known.  Cretinism,  myxedema,  Addison's  disease,  pancreatic 
diabetes,  parathyroid  tetany,  and  the  eunuchoid  state  are  clin- 
ically recognizable.  To  this  is  to  be  added  the  dystrophia  adi- 
posogenitalis,  due  to  hypophyseal  deficiency  and  possibly  hypo- 
thymism  and  hypopinealism."    (Gushing.) 

There  are  constant  changes  in  the  hypophysis  during 
pregnancy.  This  gland  is  enlarged,  and  there  is  an  increased 
secretion  in  pregnancy  on  the  part  of  the  anterior  lobe.  Tandler 
and  Gross  compare  the  frequent  changes  in  the  face  of  preg- 
nant women,  especially  the  coarseness  of  the  features,  with 
the  same  changes  occurring  in  acromegaly.  It  is  exclusively 
the  anterior  lobe  of  the  hypophysis  which  is  altered  in  preg- 
nancy. (?)  It  is  possible  that  the  periosteal  bony  growths  oi 
pregnancy  are  due  to  the  changes  in  the  hypophysis.  Whether 
the  enlargement  of  the  thyroid  in  pregnancy  stands  in  relation 


330  THE    ENDOCRINES 

to  the  hypertrophy  of  the  hypophysis  cannot  be  definitely  stated, 
neither  can  the  question  be  answered  whether  the  enlargement 
of  the  hypophysis  may  not  be  hypertrophy  designed  to  sub- 
stitute the  lack  of  function  of  the  ovaries.  It  is  also  possible 
that  the  change  in  the  hypophysis  is  the  result  of  changes  in 
the  uterus  (ovum),  and  is  designed  to  inhibit  the  function  of 
the  ovaries,  or  the  changes  of  the  hypophysis  and  the  ovaries 
may  be  due  to  a  common  cause." 

The  thyroid  enlarges  and  is  stimulated  before  each  men- 
struation by  the  corpus  luteum.  This  stimulation  persists  for 
several  months  and  is  the  greatest  protection  the  pregnant 
patient  has.  This  activity  of  the  thyroid  helps  to  hold  the 
posterior  pituitary  in  check  and  thyroid  extract  is  the  guardian 
of  the  kidney  epithelium.  In  the  infectious  diseases  as  scar- 
latina, influenza,  etc.,  the  kidneys  are  involved  by  toxins  the 
more  readily  if  the  thyroid  be  inefficient  or  if  it  be  injured  by 
the  toxins.  Pituitary  posterior  plus,  and  thyroid  minus,  are 
the  basic  factors  in  eclampsia,  in  high  blood  pressure,  and  in 
many  psychic  states.  Pituitary  posterior  plus  and  thyroid  plus 
do  not  give  high  blood  pressure,  but  are  responsible  for  many 
psychic  states  and  for  Basedow's  disease. 


CHAPTER   XX 
THE  HISTORY  AND  THE  SYMPTOMS 

If  married,  how  long? 

Number  of  children — If  sterile,  how  long  were  precautions 
taken  and  form  of  precautions  ? 
Miscarriages  ?     Curetted  ? 
Curettings  ? 

Operations?    What  done? 
Labors :    Instrumental  ?    Torn  ?    Sewed  ? 
Nursing:     How  long  a  period  of  Amenorrhea  during 
lactation  ? 

Infectious  diseases  during  childhood?     Measles,  Scarla- 
tina, Whooping-cough,  Mumps,  Pneumonia,  Diphtheria,  etc. 
Menstruation : 

When  first  established? 

Was  it  regular  ? 

Was  it  associated  with  pain? 

At  what  interv-als? 
What  infectious  diseases  since  menstruation  was  estab- 
lished ? 

How  were  you  at  school?    Standing? 

Did  you  have  to  be  taken  out  as  result  of  overwork  ? 

Menstruation  Now: 

How  often? 

How  long  does  it  last? 

Are  there  clots? 

Is  there  pain  ?    When  ? 

Last  menstruation? 

Menopause?     How  long?    In  what  form  did  it  de- 
velop ?    Flushes  ? 

Premenstrual  Phenomena : 

How  many  days  before  any  menstruation  can  you  tell 
that  you  are  going  to  be  unwell  ? 
331 


332  THE    ENDOCRINES 

What  are  the  physical  symptoms?  Breasts  full? 
Feel  discomfort  down  below?  Any  pain  or 
cramps  before  menstruation  appears  ? 

What   are   the   premenstrual   mental   and   nervous   phe- 
nomena ? 

Headache  ? 

Nausea  ? 

Excitability  ? 

Irritability  ? 

Depression  ? 

Blues? 

Do  you  cry  easily? 

Are  you  cross  with  your  children? 

Are  you  sensitive? 

Different  from  your  behavior  at  other  times  ? 

Intermenstrual  State: 
Palpitation  ? 
Any  headaches? 
Dizziness  ? 

Any  intermenstrual  pain? 
Pain  on  right  or  left  sides  ? 
Pain  in  the  back  ? 
Any  sensation  of  dropping  down? 
Constipated  ? 

Urinary  Condition : 

Frequent  urination? 

Painful  ? 

Amount  in  24  hours? 

General  Questions 
Palpitation  ? 
Heart  burn? 

Any  form  of  indigestion? 

Are  you  excitable ?    Irritable?    Nervous?    Depressed? 
Have  you  any  fears?     Any  anxieties? 
Have  you  gained  in  weight  since  marriage  or  have  you 
lost? 


THE  HISTORY  AND  THE  SYMPTOMS  333 

Are  you  menstruating  as  much,  or  more,  or  less,  than 
formerly  ? 

Are  your  premenstrual  annoyances  acquired  or  did  they 
always  exist? 

Tell  me  in  three  words  the  most  important  annoyances 
that  brought  you  to  me? 

Instincts  :  Pugnacious  ?  Gregarious  ?  Fearsome  ?  Curi- 
osity? Tastes?  Domestic?  Fond  of  books  and  home ?  Fond 
of  children?    Sex  instinct  or  urge? 

Sleep :  Long  to  fall  asleep  ?  Wake  up  after  certain 
hours  of  sleep  ?  What  keeps  you  awake  or  prevents  you  from 
falling  asleep?  Flow  of  thought?  Fears?  Worries?  Anger? 
Longing?     Dreams?     Character  of  dreams? 

Observations 

Observe  the  eyebrows ;  a  poor  development  of  the  outer 
half  implies  a  lack  of  thyroid;  shaggy  and  heavy  eyebrows 
attract  attention  to  the  anterior  pituitary  and  to  the  adrenals. 

Bulging  eyes  suggest  hyperthyroidism  and  hyperpitui- 
tarism. 

A  good  bridge  of  the  nose  means  a  good  thyroid. 

A  broad  nose  calls  attention  to  the  anterior  pituitary. 

A  good  firm  lower  jaw  suggests  the  gland  that  produces 
acromegaly, — as  does  wide  spacing  of  the  teeth. 

Regular  teeth  imply  balance  between  the  anterior  and  pos- 
terior pituitary. 

High  arch  and  crowded  teeth  suggest  overactivity  of  the 
post,  pituitary. 

Yellowish  color  of  teeth  calls  attention  to  the  adrenal 
cortex. 

Teeth  crowded  together,  with  a  high  arch,  means  rela- 
tively more  posterior  than  anterior  pituitary. 

Absent,  abnormal,  or  small  lateral  incisors  speak  for  ab- 
normal  or  poorly   developed   gonads   and   internal   genitalia. 

Thyroidal  teeth  are  firm,  white,  with  good  enamel, — often 
transparent,  with  a  suggestion  of  bluish  tint. 


334  THE    ENDOCRINES 

In  anomalies  of  the  thymus,  and  of  the  thyroid,  and  of 
the  parathyroid,  because  of  the  calcium  disturbances,  there  is 
poor  enamel,  and  with  the  parathyroid  disturbances  there  may 
be  lateral  erosions  of  the  enamel. 

Adrenal  cortex  plays  a  part  in  the  growth  of  body  and 
bones. 

Adrenalin  diminishes  the  elimination  of  calcium.  Para- 
thyroids regulate  calcium  metabolism  and  the  calcium  contents 
in  the  nervous  system.  Thymus  aids  the  assimilation  of  cal- 
cium by  bones.  Thyroid  and  pituitary  aid  in  regulating  the 
elimination  of  calcium. 

Adrenal  teeth  are  often  dark  with  a  tinge  of  yellow  or 
green. 

Long  pointed  canines  indicate  a  fighter  or  "scrapper," 
and  are  to  be  referred  to  the  adrenals.  Short,  small  canines 
suggest  the  opposite. 

AVisdom  teeth  in  their  character,  eruption,  and  date  of 
eruption  are  probably  related  to  the  anterior  pituitary. 

A  real  "peaches  and  cream"  complexion,  and  doll-like 
face,  flushing  and  blushing,  attract  attention  to  the  activity  of 
the  thyroid  and  posterior  pituitary. 

Hair  on  upper  lip,  on  the  face  or  chin,  suggests  adrenal 
cortex  action,  as  do  moles. 

Pigmentations,  moles,  freckles,  attract  attention  to  the 
adrenals. 

Dark  skin,  red  hair,  demand  a  special  study  of  adrenal 
activity. 

The  skin  of  many  asthmatics  shows  deposit  of  pigment. 

Asthma  is  referred  by  some  to  the  thyroid.  Others  look  to 
the  adrenals  as  an  important  relation.  Still  others  to  the 
hypophysis. 

From  my  own  limited  experience,  I  believe  that  the  pos- 
terior pituitary  must  receive  important  consideration. 

A  quick  pink  line  on  stroking  or  scratching  the  skin  in- 
dicates normal  adrenal  relationship. 

If  the  skin  is  stroked  with  a  pinhead,  or  the  finger  nail, 
or  the  finger,  a  white  line  may  remain,  or  it  may  grow  pink 


THE  HISTORY  AND  THE  SYMPTOMS  335 

quickly  or  very  slowly.  If  this  manipulation  produces  a  red 
line  instantly  or  quickly,  it  speaks  for  a  good  or  over-active 
thyroid,  a  good  or  active  posterior  pituitary,  or  both.  If  a 
white  line  remains  or  turns  red  slowly  the  adrenals  are  to  be 
thought  of.  Since  this  test  shows  the  relation  of  the  sympa- 
thetic and  the  vagus,  we  must  consider  the  part  of  the  body 
tested,  as  the  vegetative  system  has  cranial,  lumbar  and  sacral 
branches.     (See  page  281.)     These  tests  are  only  suggestive. 

Small,  delicate,  shapely  hands,  speak  for  a  posterior  pitui- 
tary not  overshadowed  by  anterior  lobe  activity. 

Larger  hands,  hair  on  the  arms,  suggest  anterior  pituitary. 

Soft,  delicate  skin,  with  no  hair  on  the  arms,  speaks  for 
thyroid  and  posterior  pituitary  and  no  marked  adrenal  cortex. 

Dry,  scaly  skin  speaks  for  lack  of  thyroid. 

Broad,  thick  chest,  well  developed  frame,  speak  for  an- 
terior pituitary,  even  though  the  posterior  be  normal  in  other 
respects. 

The  greater  the  male  characteristics  in  any  fashion,  the 
greater  has  been  the  relative  action  of  the  anterior  pituitary 
and  the  adrenal  cortex.  • 

The  pubic  hair  of  the  female  has  a  horizontal  upper 
border.  The  pubic  hair  of  the  male  has  a  pyramidal  upper 
border,  extending  up  toward  the  umbilicus. 

Cold  hands,  poor  circulation  of  the  hands,  especially  dur- 
ing cold  weather,  speak  for  a  lack  of  thyroid,  whereas  warm 
hands  and  feet  and  moist  skin  speak  for  good  or  overactivity 
of  the  thyroid.  The  hyperthyroid  person  may  stand  the  warm 
or  humid  weather  badly. 

A  tired  feeling,  fatigue,  so  often  described  as  neuras- 
thenia, may  be  divided  into  physical  and  mental  asthenia. 
Physical  asthenia  suggests  the  status  lymphaticus,  or  a  failure 
of  proper  adrenal  action,  a  deficiency  of  the  thyroid, — and  here 
the  young  and  adolescent  should  not  be  forgotten, — or  it  im- 
plies an  over-active  thyroid  with  excessive  basal  metabolism. 

In  hyperthyroidism  there  is  increased  stimulation  of  the 
autonomic  system  by  the  thyroid. 


336  THE    ENDOCRINES 

Exophthalmos  is,  in  my  opinion,  an  evidence  of  over- 
activity of  the  posterior  pituitary. 

The  adrenals  are  profoundly  affected  in  the  severer  forms 
of  hyperthyroidism  and  the  adrenal  test  of  Goetch,  in  my 
opinion,  is  caused  by  or  is  an  evidence  of  the  adrenal  involve- 
ment, and  is  not  an  accurate  or  adequate  test  of  hyperthyroid- 
ism as  such. 

The  thymus  is  markedly  involved,  the  more  severe  is  the 
form  of  the  hyperthyroidism. 

Thyroid  stimulates  the  chromaffin  system;  hence  the  fre- 
quent association  of  medullary  hyperadrenalism  w^ith  hyper- 
thyroidism; under  these  circumstances  suprarenal  extract 
which  contains  the  cortex  of  the  adrenals  is  indicated  to  over- 
come the  overactivity  of  both  the  thyroid  and  the  medulla. 

Thyroid  increases  the  excitability  of  the  autonomic 
nervous  system.  Parathyroid  through  its  relation  to  calcium 
metabolism  and  the  calcium  content  in  the  nervous  system 
diminishes  excitability;  hence  a  diminution  of  parathyroid 
secretion,  allowing  the  escape  of  calcium,  increases  the  degree 
of  excitability. 

The  genuine  cases  of  Graves  diseases  are  all  pluriglandu- 
lar, and  so  are  many  of  the  forms  of  hyperthyroidism  without 
exophthalmos.  In  fact,  there  is  no  such  thing  as  a  uniglandu- 
lar  involvement. 

Adrenalin  inhibits  the  pancreas;  hence  with  any  diminu- 
tion of  chromaffin  activity,  the  power  to  assimilate  carbohy- 
drates is  increased,  because  here  also  inhibition  over  the  pan- 
creas is  removed. 

The  thyroid  inhibits  the  islets  of  the  pancreas;  hence  in 
hypothyroidism  the  power  to  assimilate  carbohydrates  is  in- 
creased, since  the  inhibition  over  the  pancreas  is  removed. 

When  both  thyroid  and  pancreas  are  removed,  glycosuria 
results ;  hence  the  combination  of  thyroid  minus  and  pancreas 
minus  may  mean  glycosuria.  In  hyperthyroidism^  however, 
the  pancreas,  if  it  does  not  yield  to  inhibition  by  the  excess  of 
thyroid  and  by  the  action  of  the  chromaffin  system,  may  not. 
as  is  expected,  be  productive  of  glycosuria. 


THE   HISTORY   AND   THE   SYMPTOMS  337 

Hyperchlorhvclria  and  the  so-called  "heartburn"  of  preg- 
nancy are  probably  due  to  hyperthyroidism.  Many  claim  that 
it  is  due  to  diminished  adrenal  activity  and  that  small  doses  of 
suprarenal  extract  relieve  the  condition. 

Thyroid  increases  gastric  peristalsis. 

Adrenal  activity  checks  the  activity  of  the  stomach. 

Thyroid  inhibits  the  pancreatic  islets. 

Adrenals  dimini:,h  pancreatic  activity. 

Thyroid  stimulates  metabolism. 

Adrenal  inhibits  activity  of  the  intestinal  muscle. 

Thyroid  stimulates  metabolism. 

The  adrenals  inhibit  metabolism. 

Thyroid  checks  activity  of  the  pancreas.  Therefore  the 
hypothyroid  patient  having  an  over-active  pancreas  is  able  to 
digest  the  carbohydrates,  etc.,  in  larger  amounts;  hence  the 
craving  for  sweets.  Such  a  craving  is  said  to  be  characteristic 
of  pituitary  inadequacy. 

Too  much  adrenal  medulla  inhibits  the  gastric  secretion; 
adrenal  cortex  substance  probably  increases  the  peristalsis  of 
the  intestine. 

Judgment,  wisdom,  taste  for  books  and  literature,,  interest 
in  the  important  problems  attract  attention  to  a  good  anterior 
pituitary. 

Fondness  for  children,  normal  libido,  and  feminine  traits 
point  to  the  posterior  pituitary. 

Excessive  activity,  restlessness,  desire  for  excitement, 
mental  and  physical  "wanderlust,"  the  jumpy  type  of  indi- 
vidual suggest  overactivity  of  the  thyroid  or  of  the  posterior 
pituitary  or  both. 

Receding  gums,  pyorrhoea,  long  teeth,  suggest  posterior 
pituitary  activity. 

Varicose  veins   suggest  posterior  pituitary  overactivity. 

Fibroids  or  fibroid  nodules  of  the  uterus  speak  likewise 
for  posterior  pituitary  plus. 


338  THE   ENDOCRINES 

Occipital  headaches,  radiating  behind  the  ears,  down  the 
neck,  the  spine  or  along  the  sciatic  region,  speak  for  post, 
pituitary  plus. 

Diphtheria  and  influenza  are  especially  prone  to  affect  the 
adrenals. 

Children  with  good  thyroids  acquire  fewer  of  the  child's 
diseases,  with  the  possible  exception  of  measles,  and  stand 
these  infections  well. 

The  pneumococcus  affects  badly  the  chromaffin  system  of 
the  adrenals. 

The  pneumococcus  may  profoundly  influence  the  gonads. 

Mumps  readily  affects  the  gonads. 

Syphilis  seems  to  take  a  more  severe  form  when  the 
pituitary  is  inefficient. 

Tuberculosis  not  infrequently  means  abnormal  adrenal 
relation  or  balance. 

If  pregnancy  is  associated  with  thyroid  minus  the  danger 
of  toxemia  and  eclampsia  and  increased  blood  pressure  is 
enhanced. 

Reference  is  to  be  made  to  the  interglandular  changes 
and  readjustments  of  puberty  and  the  adolescent  period.  Here 
we  have  the  introduction  of  the  specific  sex  glands  (the 
gonads).  This  is  a  period  of  growth  and  increased  activity  in 
preparation  for  the  most  active  period  of  life.  It  is  as  truly  a 
change  of  life  period  involving  physical,  visceral,  mental, 
physic  and  endocrine  phases  as  is  the  period  known  as  the  cli- 
macterium. 

When  a  woman  goes  through  the  so-called  "change  of 
life"  period,  there  is  a  rearrangement  of  the  glands  and  their 
relative  degrees  of  dominance  are  altered.  If  they  all  regress 
in  equal  ratio  and  their  former  normal  balance  is  well  pre- 
served, the  woman  goes  through  this  trying  period  with  few  if 
any  manifestations  of  a  physical,  functional,  or  physic  nature. 
But  if  the  rearrangement  has  not  been  one  of  parallel  retro- 
gression we  have  all  the  innumerable  variations  during  which 
the  anterior  or  posterior  pituitary,  the  thyroid,  the  adrenal 
cortex,  the  adrenal  medulla  and  the  other  ductless  structures  of 


THE   HISTORY  AND  THE   SYMPTOMS  339 

the  body  are  so  changed  in  interrelation  that  they  produce  in- 
numerable combinations,  according  to  their  overactivity,  un- 
deractivity, and  interactivity. 

These  changes  are  of  varying  significance  and  meaning 
according  to  heredity,  inherent  instincts  and  emotions  and 
according  to  their  play  up  to  this  period. 

And  so  the  picture  may  be  dominated  by  hyperovarianism 
(interstitial  or  glandular),  hyperpituitarism  (anterior  or  pos- 
terior), hyperthyroidism,  hyperadrenalism  (cortical  or  medul- 
lary) ;  or  by  hypoovarianism  (interstitial  or  glandular),  hypo- 
pituitarism (anterior  or  posterior),  hypothyroidism,  hypo- 
adrenalism  (cortical  or  medullary)  ;  or  by  various  inter- 
minglings  and  continued  changes  of  interrelations. 

The  flushes  of  the  menopause  period  and  those  which 
take  place  after  the  removal  of  the  ovaries  or  on  atrophy  of 
the  ovary  or  ovaries  retained  after  hysterectomy,  are  due  not 
only  to  the  absence  of  the  ovarian  interstitial  secretion  but  to 
the  overactivity  of  other  glands  acting  on  the  vasomotor  sys- 
tem, and  the  overactivity  which  is  most  responsible  for  the 
flushes  is  to  be  referred  to  the  posterior  pituitary,  and  asso- 
ciated are  the  adrenals. 

Therefore  ovarian  secretion,  related  to  the  posterior  pitui- 
tary function  and  to  the  adrenals,  is  in  a  degree  responsible  for" 
upset  of  balance  in  this  vasomotor  phase.  The  interstitial 
gland  stimulates  the  adrenal  cortex  function. 

Because  of  its  importance  let  me  repeat  that  there  is  a 
great  difference  between  the  action  of  adrenal  medulla  and 
adrenal  cortex,  between  anterior  pituitary  and  posterior  pitui-* 
tary,  between  the  interstitial  ovary  and  the  glandular  portion. 

The  adrenal  medulla  and  the  adrenal  cortex  represent  a 
balance  as  is  the  case  with  the  anterior  and  posterior  lobes  of 
the  pituitary.  As  the  anterior  pituitary  plays  the  greater  part 
in  the  male  than  in  the  female,  and  as  the  posterior  pituitary 
plays  a  greater  part  in  the  female  than  in  the  male,  so  does 
the  adrenal  cortex  play  a  greater  part  and  is  more  active  in  the 
male  than  in  the  female.  Since  the  adrenal  medulla  is  asso- 
ciated with  the  other  chromaffin  structures  in  the  emotion  of 


340    '  THE    ENDOCRINES 

fear,  and  since  the  whole  adrenal  stability  is  less  in  the  female 
than  in  the  male,  and  since  post  pituitary  action  is  more 
marked  in  the  female,  so  is  the  female  more  subject  to  fear. 

When  action  of  the  cortex  is  associated  with  action  of  the 
medulla,  fear  is  less  marked  and  pugnacity  or  anger  is  more 
marked.  Phobias  imply  a  lack  of  sufficient  action  or  supply 
of  adrenal  cortex,  and  of  anterior  pituitary  and  excess  of  pos- 
terior pituitary  and  adrenal  medulla.  Since  the  adrenal  cortex 
is  stimulated  by  the  cells  of  Leydig  and  these  two  secretory 
glands  are  closely  related  to  the  anterior  pituitary,  so  is  the 
instinct  of  pugnacity  the  greater  in  men.  With  this  character- 
istic in  women,  attention  is  called  to  the  interstitial  ovary  and 
adrenal  cortex. 

If  these  changes  are  productive  of  alterations  of  a  pre- 
dominantly physical  type,  they  are  manifested  to  the  eye.  If 
the  changes  are  productive  of  visceral  alterations,  they  have 
their  specific  symptoms  evidenced,  for  instance,  by  the  pulse- 
rate,  gastro-intestinal  functions,  the  amount  of  urinary  excre- 
tion, etc.  If  the  manifestations  of  altered  gland  activities  are 
psychic,  we  have  all  the  variations  in  the  way  of  overexcitabil- 
ity,  irritability,  states  of  depression,  states  of  anxiety,  etc.,  up 
to  the  grade  of  psychosis. 

Any  or  many  of  the  changes,  such  as  those  visible  to  the 
eye,  the  internal  alterations  in  visceral  or  circulatory  or  meta- 
bolic function  as  well  as  the  varying  psychic  deviations  from 
the  normal,  may  be  intermingled. 

The  changes  may  be  slight  or  great,  temporary  or  lasting, 
evanescent  or  more  or  less  permanent.  For  these  reasons  it 
is  no  wonder  that  the  period  of  the  climacterium  is  a  most 
trying  one. 

The  libido  or  sex  urge  may  be  increased  or  diminished  or 
altered  at  this  period.  When  increased,  as  it  may  be,  it  speaks 
in  all  probability  for  a  relative  or  actual  increase  of  the  pos- 
terior pituitary. 

Acromegaly 

This  condition,  due  to  excessive  activity  of  the  Ant.  Hypo- 
physis, is  frequently  associated  with  abnormal  function  of  the 


THE  HISTORY  AND  THE  SYMPTOMS  341 

thyroid,  increased  action  of  the  interstitial  glands;  very  often 
with  loss  of  the  genital  function  after  preliminary  transitory 
increase,  and  often  with  hyperplasia  of  the  supra-renal  cortex. 
Important  Symptoms: 

The  nose  is  very  much  thickened. 

The  malar  bones  protrude. 

There  is  a  spreading  apart  of  the  teeth. 

Enlargement  of  the  upper  jaw. 

Enlargement  of  the  lower  jaw. 

The  mucous  membrane  of  the  tongue  is  thickened. 

There  may  be  increased  muscular  strength  in  the  early 
stages, — shortly  followed  by  rapid  increase  in  the  way  of 
fatigue,  due  to  marked  muscular  weakness.  Such  muscles 
shozv  increase  of  connective  tissue,  and  degeneration  and  atro- 
phy of  the  muscle  fibres.  (Falta.) 

The  growth  of  hair  on  the  head  is  increased  and  the  in- 
dividual hairs  are  thick. 

The  hairiness  in  women  assumes  the  male  type. 

After  early  stimulation,  there  is  a  diminution  in  the  func- 
tion of  the  ovary. 

Varying  degrees  of  hyperthyroidism  may  be  associated 
with  acromegaly. 

A  slight  degree  of  arterio-sclerosis  is  an  associated  phe- 
nomenon. 

The  cardiac  muscle  undergoes  degeneration  and  enlarge- 
ment.    (Falta.) 

There  is  a  frequent  tendency  to  glycosuria  or  diabetes 
mellitus  (due  to  excess  of  post.  lobe).     Bandler. 

Rheumatoid  pains  are  frequent,  and  the  pains  often  occur 
during  the  night. 

There  are  sensations  of  heat  in  the  fingers. 
In  many  cases  there  is  a  mental  apathy,  a  lack  of  initia- 
tive, and  a  slowing  of  the  speech. 

Acromegaly  may  be  combined  with  hyper-  or  hypo-thy- 
roidism. 

The  rise  in  blood  pressure  which  follows  pituitrin  (post. 


342  THE    ENDOCRINES 

lobe)    generally   disappears   after   short   repeated   injections; 
whereas  that  of  adrenalin,  with  the  same  methods,  persists. 

Pituitrin  acts  a  diuretic.     (Overactivity  of  the  pituitary 
posterior  may  diminish  the  amount  of  urine,  Bandler.) 
Hypo-Pituitarism 

Accumulations  of  fat  in  definite  locations. 

Marked  obesity. 

Atrophy  of  the  interstitial  glands  and  the  glands  of  gen- 
eration. 

Occasional  retrogression  of  the  secondary  sex  character- 
istics. 

In  the  early  years  there  is  inhibition  of  growth  and  in- 
hibition of  ossification. 

Polyuria. 

There  is  in  these  patients  restlessness  and  resignation; 
so  that  in  spite  of  headaches  they  are  gay  and  happy. 

This  gay  temperament  contrasts  with  the  stupidity  and 
moroseness  of  hypo-thyroidism  in  childhood. 

In  hypo-pituitarism  there  is  a  lack  of  interest. 

There  may  be  psychoses.     (Falta.) 

Tetany 

Tetany  represents  an  abnormally  increased  condition  of 
excitement  of  the  nervous  system,  demonstrable  in  a  height- 
ened excitability  of  the  motor,  sensory,  and  vegetative  nerves 
with  painful  spasms.  The  manifestations  are  the  result  of 
an  insufficiency  of  the  parathyroid  glands.     (Falta.) 

The  most  typical-  symptom  is  the  tetanic  spasm,  usually 
afifecting  the  upper  extremities.  There  may  be  spasms  of 
the  eyelids,  of  the  mouth,  yawning  spasms,  strabismus,  in- 
volvement of  the  larynx,  causing  laryngo -spasm. 

In  children  the  sensorium  may  be  clouded. 

In  acute  cases  there  are  occasionally  hallucinatory  con- 
fusion or  deep  depression. 

There  may  be  abnormal  psychical  excitement,  or  even  de- 
pression. 


THE   HISTORY  AND  THE   SYMPTOMS  343 

The  vegetative  nerves  are  excitable,  or  there  is  increase  in 
tonus. 

In  the  acute  stages  there  is  pronounced  dermographism. 

There  is  frequently  observed  pain  in  the  bones  or  joints. 

After  infection  of  adrenalin  in  the  acute  stages^  there  is 
increased  blood  pressure,  heart  action,  and  the  vessels  of  the 
skin  are  contracted.     (Falta.) 

The  face  becomes  pale  as  well  as  the  entire  body,  and 
there  is  palpitation. 

In  the  acute  stages  of  tetany  in  adults  there  is  marked 
pallor. 

There  are  muscular  spasms  of  the  fingers  and  toes,  and 
there  is  a  characteristic  puffiness  of  the  face. 

The  facial  pallor  differs  from  the  livid  color  of  myx- 
oedema.  (Livid — black  and  blue;  of  a  lead  color;  like  a 
bruise.) 

There  may  be  disturbance  of  the  gastro-intestinal  tract. 

It  is  possible  that  tetany  increases  the  pyloric  spasm  or 
causes  it. 

In  acute  tetany  there  is  irritability  of  the  central  nervous 
system,  of  the  peripheral  nerves,  and  of  the  vegetative  nervous 
system.     (Falta.) 

MacCallum  finds  diminished  calcium  contents  in  tetany, 
with  increased  elimination  through  the  kidneys  and  intestine. 

The  hair,  the  nails,  the  skin,  the  enamel  are  trophically 
disturbed. 

There  is  a  tendency  to  falling  out  of  the  hair. 

There  is  a  tendency  to  the  formation  of  cataracts, — and 
there  is  hypoplasia  of  enamel,  causing  the  formation  of  hori- 
zontally transverse  ridges. 

The  incisor  teeth  are  the  most  sensitive,  shozving  opaque 
spots  on  the  anterior  surface. 

There  is  a  tendency  to  the  association  of  hyperthyroidism. 

Falta  states  that  the  cause  of  tetanic  changes  lies  in  the 
ganglion  cells  of  the  spinal  cord, — even  though  the  higher 
centers  are  hyper-excitable. 


344  THE   ENDOCRINES 

The  coindence  of  tetany  and  myotonia  has  been  ascribed 
to  insufficiency  of  the  parathyroids,  but  Falta  considers  myo- 
tonia an  affection  of  the  muscles,  and  the  symptoms  of  tetany 
resembling  myotonia  he  explains  on  a  metabolic  basis. 

It  is  stated  that  individuals  zvho  in  early  years  have 
passed  through  tetany  later  often  become  epileptics. 

Osteomalacia  is  supposed  to  be  associated  with  over- 
activity of  the  parathyroids. 

Thymus  Gland 

Thymic  hyperplasia,  status  lymphaticus,  narrowing  of 
the  arch  of  the  aorta,  resulting  in  death,  are  viewed  as  a  vege- 
tative disturbance  to  which  is  given  the  name  of  lymphato- 
chlorotic  constitution. 

An  abnormally  large  thymus  without  status  lymphaticus 
is  called  a  status  thymicus. 

Status  lymphaticus  is  associated  with  a  hyperplasia  of 
the  chromaffin  system. 

Thymus  hyperplasia  is  frequently  found  in  Basedow's 
disease,  acromegaly,  pituitary  dystrophy,  myxoedema,  etc. 

It  is  found  with  both  hyper  and  hypo-function  of  the 
other  glands.     (Falta.) 

Thyroid 

Two  lobes  on  either  side  of  the  trachea  connected  by  an 
isthmus.  Contains  follicles  lined  with  epithelium  and  filled 
with  colloid  containing  the  specific  secretion  which  is  absorbed 
into  the  circulation  through  lymph  channels.  The  iodine  con- 
tent is  high.     (Falta.) 

Thyroiditis;  often  associated  with  and  resulting  from 
acute  infectious  diseases.  It  may  lead  to  hyperthyroidism  and 
Basedow's. 

Alay  be  affected  after  operation,  during  pregnancy,  after 
labor,  etc. 

Basedow's  (a  pluriglandular  disease) 
Increased  activity  of  the  thyroid ;  generally  enlarged. 
Tachycardia,    exophthalmos,    tremor,    digestive    disturb- 
ances, nervousness,  increased  metabolism. 


THE   HISTORY   AND   THE   SYMPTOMS  345 

Vegetative  system  excited. 

Rare  in  children;  eight  times  more  frequent  in  women 
than  men ;  often  famihal. 

Plus  or  minus  often  associated  with  neuroses,  diabetes 
and  phychoses  as  family  characteristics. 

Blood  pressure  normal  or  lozc. 

The  administration  of  thyroid  lowers  blood  pressure. 

Reddening  of  the  face,  ears,  tips  of  the  fingers,  due  to 
poor  peripheral  tonus. 

Increased  sensitiveness  to  adrenalin  on  the  part  of  the 
sympathetic. 

Scratching  of  throat,  irritating  cough. 

Increased  frequency  of  respiration,  air-hunger, — paroxy- 
smal and  early. 

Tremor  increased  by  psychic  emotions ;  produeed  or  in- 
creased by  the  administration  of  thyroid. 

Headache  and  especially  insomnia  may  be  the  initial  symp- 
toms. 

Alental.  Irritability,  gaiety  without  cause,  hasty  speech, 
rapid  flow  of  thought,  changes  of  mood,  mistrustful,  capricious, 
elated,  depressed. 

Attacks  of  vomiting,  watery  diarrhoeas,  increased  diu- 
resis. 

Increased  saliva ;  diminished  saliva. 

Coagulation  time  of  the  blood  is  increased  and  length- 
ened. 

Alononucleosis  which  is  increased  on  the  administration 
of  thyroid  (mononucleosis  diminished  in  hypothyroidism). 

Neutrophiles  diminished. 

"The  thymus  is  hyperplastic  in  forty-five  per  cent,  of  Base- 
dow's dying  of  intercurrent  diseases,  and  eighty-two  per  cent, 
of  Basedow's  dying  of  the  disease  itself,  and  nearl\  one  hun- 
dred per  cent,  dying  on  operation.  Death  probably  due  to 
status  lymphaticus  or  failure  of  chromatin  organs."    (Falta.) 

Emaciation  frequent  (in  rare  cases  obesity). 

Appetite  often  increased,  yet  emaciation  results  through 
increased  caloric  production  stimulated  by  thyroid  excess. 


346  THE   ENDOCRINES 

(Tremor  diminished  by  hyoscine.)  Change  in  the  meta- 
bolism due  to  increase  of  the  tonus  of  the  vegetative  nervous 
system  and  the  heightened  activity  of  the  organs  which  sup- 
ply it. 

Caloric  production  increased.  Disturbance  in  the  regula- 
tory mechanism  that  governs  the  taking  up  of  nutrition.  Dis- 
turbances of  stomach  and  intestines. 

Albumin  exchange  is  increased.  More  albumin  is  needed 
to  maintain  nitrogen  equilibrium. 

The  exchange  after  injection  of  food  is  abnormal,  the 
metabolism  is  especially  labile.  The  administration  of  albumin 
perhaps  increases  the  activity  of  the  thyroid. 

Combination  of  Basedow's  with  true  diabetes  is  not  rare. 

Hyperthyroidism  favors  a  predisposition  to  glycosuria. 
Hyperthyroidism  possibly  inhibits  the  secretory  activity  of 
the  pancreas. 

Glycosuria  disappears  with  retrogression  of  the  hyper- 
thyroidism. 

In  normal  individuals  the  action  of  thyroid  extract  on 
gas  exchange,  albumin,  and  the  carbohydrate  metabolism  is 
often  intense,  while  in  other  individuals  it  has  little  if  any 
effect. 

Thyroid  gland  secretion  increases  the  elimination  of  phos- 
phorus through  the  intestine.  The  abnormal  distribution  of 
phosphorus  to  the  kidneys  and  intestine  is  called  forth  by  an 
increase  of  the  calcium  elimination  by  way  of  the  intestine. 

In  many  cases  of  Basedow's  disease  there  is  a  pronounced 
polyuria. 

The  temperature  in  severe  Basedow's  may  be  associated 
with  transitory  rises  of  temperature. 

The  skin  is  delicate,  pliable,  moist,  readily  reddened, 
through  a  lively  play  of  the  vaso-motors. 

Increased  sweating  is  almost  constant. 

Pigmentations  are  found  in  half  of  the  cases  on  the 
eyelids,  lips,  throat,  nipples,  axillae  and  linea  alba,  occasionally 
on  the  genitalia.  Edematous  swellings  may  occur  of  the  eye- 
lids or  extremities.    They  do  not  pit  on  pressure.     (Falta.) 


THE   HISTORY  AND   THE   SYMPTOMS  347 

Falling  out  of  the  hair  is  frequent.  The  nails  are  some- 
times fissured. 

Youthful  patients  show  an  exhilarated  growth  in  height 
and  a  premature  closure  of  the  epiphysial  junctures. 

The  skeleton  is  usually  slender. 

Basedow's  and  rheumatoid-arthritis  may  occur  together. 

Alterations  in  menstruation  occur.  Amenorrhoea  may 
be  an  early  symptom.  The  thyroid  increases  in  size  during 
puberty  and  pregnancy. 

Frequent  tachycardia  at  puberty. 

In  Basedow's  the  hair  may  be  dry  but  it  is  thin.  In 
myxoedema  it  is  thick,  loose  and  brittle. 

A  Basedow's  case  may  go  over  to  myxoedema. 

Thyroid  and  hypophysis  may  be  affected  at  the  same  time, 
and  many  of  the  so-called  myxoedema  symptoms  in  Basedow's 
may  be  due  to  hypophysis  minus. 

The  iodine  content  of  the  thyroid  gland  is  larger  than 
that  of  the  skin,  lungs,  ovaries,  small  intestine,  blood,  liver, 
bile,  hair  and  the  anterior  hypophysis.     (Falta.) 

The  thyroid  glands  of  new-born  children  are  iodine-free. 

Copious  feeding  of  meat  to  dogs  makes  the  thyroid  gland 
poor  in  iodine  and  the  glands  of  carnivorse  have  the  lowest 
iodine  contents. 

Scleroderma  occurs  in  Basedow's. 

Symptoms  common  to  both  myxoedema  and  Basedow 
are  certain  forms  of  edema,  dryness  and  grayness  of  the  hair, 
pigmentations,  etc.  Certain  cases  of  Basedow  may  have  a  dry 
skin  and  occasionally  a  glycosuria  may  develop  in  myxoedema. 
These  differences  depend  upon  varying  degrees  of  tonus  of 
the  sympathetic  or  of  the  autonomous.  (These  are  possibly  due 
to  the  interstitial  and  glandular  thyroid  which  are  antagonists. 
Bandler.) 

Excitation  predominating  on  the  part  of  the  vagus  or  of 
the  sympathetic  nerves  gives  two  forms.  1.  Vagotonic;  slight 
tachycardia,  Graefe,  wide  palpebrial  fissures,  sweats,  diar- 
rhoeas, hyperacidity,  disturbances  of  respiration,  no  alimentary 
glycosuria.    2.  Sympathicotonic ;  exophthalmos,  marked  tachy- 


348  THE   ENDOCRINES 

cardia,  no  sweats  or  diarrhoea,  marked  falling-out  of  the  hair, 
no  disturbances  of  respiration,  positive  alimentary  glycosuria. 
(Falta.) 

In  certain  cases  the  differences  depend  on  the  predom- 
inance of  one  or  the  other  of  the  two  systems. 

Applying  to  the  sera  of  Basedow's  the  reaction  of  Abder- 
halden,  Lampe  finds  in  the  sera  ferments  against  ovaries,  thy- 
roid and  thymus  only. 

Plummer  divides  goitres  with  symptoms  of  intoxication 
into  1,  exophthalmic;  2,  non-exophthalmic. 

1,  is  true  hypertrophy  and  hyperplasia  of  the  gland  tissue. 

2,  is  increased  parenchyma,  through  regenerative  changes 
or  new  formation  with  increase  of  secretory  action  and  ab- 
sorption. 

Sea-coasts  are  almost  free  from  goitre  and  cretinism. 

Myxoedema 

Diminished  function  of  the  thyroid,  diminution  of  all 
vital  processes  of  body  and  mind,  slowing  of  metabolism  and 
of  excitability.  Trophic  disturbances  affect  especially  the  ecto- 
derm, skin,  hair,  nails  and  teeth  and  the  vascular  system  {pre- 
mature arteriosclerosis. )     ( Falta. ) 

Skin — Myxoedematous  swelling  of  the  entire  body,  es- 
pecially cheeks,  lids,  nose,  supraclavicular  fossa,  neck,  back  of 
hands  and  feet.    Cheeks,  nose  and  lips  may  be  blueish-red. 

Voice — Harsh ;  singing  impossible. 

Skin  elastic  (no  pitting),  dry  and  scaly. 

Hair  of  the  head  and  beard,  eyebrows,  axillary  and  pubic 
dry,  brittle,  tend  to  fall  out.  Tendency  to  baldness,  nails  dry 
and  cracked. 

Circulation — Sluggish,  sensation  of  chilliness,  pulse  small 
and  weak  and  slow;  dyspnoea  occurs  easily.  Excitability  of 
the  sympathetic  nerves  diminished,  hence  failure  of  sweat  se- 
cretion. 

Often  marked  arteriosclerosis. 

Mental  sluggishness,  retardation  of  psyche,  inability  to 
form  rapid  conclusions,  slow  and  monotonous  speech,  dullness. 


THE   HISTORY   AND   THE  SYMPTOMS  349 

brooding,  sleepiness,  little  reaction  to  strong-  stimuli.  Memory 
for  recent  events  poor. 

Psychoses  vary.    Depressed  types  predominate. 

Frequent  paresthesia  and  rheumatic  pains. 

Blood — Decrease  of  red  cells  and  hemoglobin.  Increased 
coagulability.    Mononeucleosis  and  hypereosinophilia. 

(Often  illusions,  hallucinations,  frank  psychoses.) 

Metabolism  markedly  reduced. 

Urine  diminished,  often  slight  albumin.  Increased  toler- 
ance for  sugar. 

Combinations  of  myxoedema  and  diabetes  very  rare. 

Lowered  temperature. 

Irregular  menstruation.  Either  amenorrhoea  or  menor- 
rhagia. 

Hypophysis  often  disturbed. 

Minor  forms  produce  muscular  pain,  backache,  lassitude 
in  the  morning,  constipation,  amenorrhoea  or  menorrhagia, 
the  hair  begins  to  fall  out  over  the  occiput.  Occasionally  thy- 
roid obesity. 

Cretinism  may  be  congenital  or  develop  in  early  life. 

Thyro-aplasia  is  shown  early  in  the  first  year  of  life. 
Infantile  myxoedema  appears  in  the  fifth  or  sixth  year  of 
life.  We  may  have  thyro-aplasia,  thyro-hypoplasia,  and  later 
and  in  adults  thyro-atrophy. 

Retardation  in  bone  development  produces  proportional 
drawfism  with  delayed  closure  of  the  fontanelles,  and  a  cir- 
cumference of  skull  of  greater  proportion  than  the  height. 
Retraction  of  the  root  of  the  nose  through  lack  of  growth  of 
the  vomer.     ( Falta. ) 

Disturbances  in  dentition. 

Umbilical  hernia. 

The   skin  is  myxoedematous.      In   older  cases   atrophic. 

The  limit  of  the  hair-zone  is  far  back  on  the  forehead. 

The  palatine  arches  are  high ;  tonsils  and  adenoids. 

Breathing  slow.  Marked  under  development  of  genitalia, 
external  and  internal. 

No  pubic  and  axillary  hair. 


350 


THE   ENDOCRINES 


Testes  do  not  descend  or  descend  late  and  are  smaller. 

Blood — Hemoglobin  reduced.  Increase  of  mononuclears. 
Reduced  polymorphneutrophiles. 

Bone  disturbances  are  not  in  the  epipheses  alone,  but  in 
the  bone  marrozv.    Slight  status  lymphaticus. 

Hypothermia. 

Thymus  gland  often  hypo. 

Absence  or  backwardness  of  mental  and  psychical  develop- 
ment. Inability  to  balance  head,  to  sit  and  to  walk;  that  is, 
movements  of  finer  co-ordination.     (Falta.) 

Hearing  may  be  diminished  or  absent. 

Table  of  Kocher 


Cachexia  Thyreopriva 

Absence  or  atrophy  of  the 
thyroid  gland. 

Slow,  small,  regular  pulse. 


On  application  of  cold  to 
the  skin  all  vasomotor  changes 
are  absent. 

Listless,  quiet  gaze  without 
expression   or   animation. 

Narrow  palpebral  fissures. 

Retarded  digestion  and  ex- 
cretion, poor  appetite,  few  de- 
mands. 

Slowed  metabolism. 

Thick,  non-transparent, 
folded,  dry  to  scaly  skin. 

Short,  thick  fingers  often 
broadened  at  the  ends.  Sleep- 
iness and  tendency  to  sleep. 


Morbus  Basedowi 

Swelling  of  the  thyroid 
gland — mostly  of  a  diffuse  na- 
ture, hyper-vascularization. 

Frequent,  often  tense,  rap- 
id, now  and  then  irregular 
pulse. 

Extraordinary  irritable  vas- 
cular nervous  system. 

Anxious,  unsteady  gaze 
which  is  choleric  on  fixation. 

Wide  palpebral  fissures,  ex- 
ophthalmos. 

Abundant  evacuations, 
mostly  abnormal  appetite.  In- 
creased demands. 

Increased  metabolism. 

Thin,  transparent,  finely  in- 
jected, moist  skin. 

Long,  slender  fingers  with 
pointed  end  phalanges. 


THE  HISTORY  AND   THE   SYMPTOMS 


351 


Deficiency  of  thoughts,  Hst- 
lessness  and  loss  of  emotivity. 

Retarded  sensation,  apper- 
ception and  action. 

Awkwardness    and   clumsi- 
ness. 


Stiffness  of  the  extremities. 


Sleeplessness  and  disturbed 
sleep. 

Accelerated  sensation,  ap- 
perception and  action. 

Flight  of  thoughts,  psychic 
excitement  as  far  as  hallucina- 
tion, mania  and  melancholia. 

Constant  unrest  and  haste. 

Trembling  extremities,  in- 
creased mobility  of  the  joints. 


Remaining  behind  of  bone 
g  r  o  w  t  h — short  and  thick, 
often  deformed,  bones, 

Constant  feeling  of  cold. 
Retarded,  heavy  breathing. 


Increase  of  body  weight. 

Senile    appearance,    e  v  e  n 
when  the  patients  are  young. 


Slender,  skeletal  build,  now 
and  then  weak  and  thin  bones. 


Unbearable 
heat. 


sensation     of 


Superficial  breathing  with 
deficient  inspiratory  expansion 
of  the  thorax. 

Reduction  of  body  weight. 

Youthful  luxuriant  body 
development,  at  least  in  the 
initial  stages. 


Adrenals 

Supra-renals  are  made  up  of  cortex  and  medulla.  The 
medulla  is  chromaffin. 

Accumulations  of  chromaffin  tissue  exist  independent  of 
the  supra-renals. 

Accumulations  of  cortical  substance  are  found  at  the  hilus 
of  the  kidney,  in  the  renal  substance,  along  the  supra-renal 
veins,  and  in  the  internal  genitalia. 

Either  cortical  or  medulla  cells  may  be  carried  down  with 
the  descent  of  the  genital  organs. 


352  THE    ENDOCRINES 

Adrenalin.     (Falta.) 

It  influences  muscular  power. 

The  function  of  the  cortical  system  (which  to  the  gyne- 
cologist is  important,  Bandler),  is  not  generally  known. 

It  acts  as  a  toning  influence  on  the  autonomous  nerves, 
and  may  be  an  antagonist  of  the  chromaflin  system.  (It  is, 
Bandler. ) 

Of  all  the  infectious  diseases,  diphtheria  toxin  has  the 
most  injurious  effect  on  the  supra-renals. 

Adenomas  of  the  supra-renal  cortex  are  associated  with 
hyperfunction  of  cortex. 

Tumors  of  the  Supra-renal  Cortex  cause  a  prema- 
ture development  of  the  entire  organism,  in  many  respects 
similar  to  that  observed  in  the  development  of  tumors  of  the 
pineal  gland. 

The  majority  of  the  supra-renal  tumors  affect  girls,  and 
the  result  is  excessive  development  of  the  secondary  sexual 
characteristics  and  of  the  external  genitalia.  There  is  fre- 
quently adiposity,  accelerated  growth,  and  accelerated  ossifica- 
tion and  dentition;  the  development  of  the  psyche,  and  the 
sexual  instincts  do  not  keep  pace. 

When  cortical  tumors  develop  in  the  fully  developed  or- 
gans there  are  pronounced  disturbances  of  the  functions  of 
the  sex  glands.  There  is  involution  of  the  uterus,  and  ten- 
dency to  obesity,  to  the  development  of  hairyness  of  a  mascu- 
line type.  In  pregnancy  hair  begins  to  grow  in  places  that 
represent  the  male  type. 

It  is  probable  that  there  is  a  hyperplasia  of  the  supra- 
renal cortex  in  acromegaly,  and  in  acromegaly  there  is  often 
abundant  hairiness. 

Hyperplasia  of  cortex  causes  rapid  growth  of  the  or- 
ganism ;  premature  development  of  the  secondary  sexual  char- 
acteristics; of  the  genitalia;  and  in  adults,  abnormal  hairy 
growth.     (Falta.) 

Supra-renal  Medulla 

Hyperplasia  of  the  chromaffin  tissue  produces  a  tall, 
7x/eak  individual. 


THE   HISTORY   AND  THE   SYMPTOMS  353 

The  association  of  multiple  skin  fibromata  with  tumors 
of  the  supra-renal  medulla  is  extremely  suggestive  and  the 
role  of  the  pituitary  must  not  be  overlooked  (my  own  state- 
ment). 

Interstitial  nephritis  is  associated  unth  an  increase  of  func- 
tion of  the  chromaffin  tissue.  It  is  possible  that  the  same  holds 
true  in  the  arteriosclerosis  of  diabetics.     (Falta.) 

With  hyperplasia  of  chromaffin  tissue  there  may  be  in- 
creased diuresis  and  increased  amount  of  sugar  in  the  blood. 

Adrenalin  increases  the  blood  pressure,  shallows  the 
respiration,  increases  the  excitability  of  the  striated  muscles. 
It  relaxes  the  stomach  and  intestines,  and  contracts  the  pyloric, 
ileo-coecal,  and  internal  sphincter  of  the  anus.     (Falta.) 

It  contracts  the  uterine  muscle. 

It  produces  hyperglycemia  and  glycosuria. 

It  acts  mainly  on  the  sympathetic  nerve  ends. 

The  function  of  chromaffin  tissue  is  to  maintain  normal 
excitability  of  the  sympathetic  nerves. 

It  is  concerned  with  the  regulation  of  blood  pressure,  dis- 
tribution of  the  blood ;  preservation  of  the  tonus  of  organs 
innervated  by  the  sympathetic ;  maintains  constant  the  sugar  of 
the  blood,  and  is  intimately  related  to  metabolism.     (Falta.) 
Addison's  Disease. 

Loss  of  weight  through  gastro-intestinal  disturbances. 

Pigmentation;  especially  apt  to  begin  on  the  border  of 
the  lids,  about  the  nipples,  the  linea  alba,  genitalia,  and  anal 
folds,  the  folds  of  the  palms, — but  the  palms,  soles,  and  nail 
beds  usually  remain  free.     (Falta.) 

Mucous  membrane  may  show  pigmentation, — on  the  bor- 
ders of  the  lips,  mucous  membranes  of  the  cheek,  soft  palate, 
and  on  the  borders  of  the  tongue. 

Low  blood  pressure ;  low  sugar  content  of  the  blood,  and 
tolerance  for  grape  sugar. 

Lack  of  strength;  mono-nucleosis,  or  the  status  lymphat- 
icus  which  sometimes  belongs  to  the  chromaffin  apparatus. 

The  cortical  system  is  responsible  for  the  disorders  of 


OOH-  THE    ENDOCRINES 

the  gastro-intestinal  tract,  the  vomiting,  the  diarrhoea,  the 
psychic  alterations,  convulsions,  delirium,  and  coma.     (Falta.) 

These  distinctions  are  not  yet  verified. 

It  is  possible  that  both  the  cortex  and  the  chromaffin  take 
part  in  pigment  formation. 

The  symptoms  of  acute  Addison's  may  be  that  of  unusual 
slowing  of  the  fully  tense,  slow  pulse;  violent  intestinal  colics 
occurring  in  attacks;  failure  of  peristalsis;  and  isolated  in- 
testinal DILATATIONS. 


CHAPTER    XXI 

CLINICS 

Post-Graduate  Hospital 
March  12,  1920 

Case.  The  patient  is  a  woman,  32  years  of  age,  married 
three  years,  who  came  to  this  chnic  for  sterility.  For  the  last 
two  years  she  has  had  pain  in  the  left  lower  abdomen,  inter- 
mittent, but  not  influenced  by  menstruation.  Menstruation  be- 
gan at  18,  regular  every  four  weeks,  moderate  in  amount, 
lasting  three  days,  without  dysmenorrhea.  Last  menstruation 
February  16th.  Bowels  regular;  urinary  frequency  not  in- 
creased. 

Note  that  the  menstruation  did  not  begin  until  18;  that  is 
a  late  development.  What  is  the  most  marvellous  part  of  this 
history?  That  her  bowels  move  every  day  and  she  does  not 
have  to  take  cathartics.  So  far  as  the  sterility  is  concerned, 
we  can  make  no  definite  diagnosis  as  to  the  cause  until  we  have 
examined  into  the  matter  of  the  spermatozoa.  It  is  always 
wise  to  do  that  before  considering  the  use  of  the  curette,  and 
yet  I  have  seen  patients  curetted  twice  and  even  three  times 
when  the  spermatozoa  were  absent.  That  such  things  have 
been  done  and  are  still  being  done  is  very  little  to  the  credit  of 
the  medical  profession,  and  I  have  often  said  that  I  wished  that 
before  any  doctor  was  allowed  to  use  the  curette  he  would  have 
to  get  a  permit  from  the  local  Board  of  Health  and  give  his 
reasons  for  wishing  to  use  it.  If  the  partner  has  no  spermato- 
zoa, there  is  nothing  more  to  be  said.  If  the  partner  has  sper- 
matozoa, there  is  enough  in  this  patient  to  be  the  cause  of 
sterility.  Don't  forget  that  she  did  not  begin  to  menstruate 
until  18  years  of  age.  That  is  a  very  late  development  of  the 
menstrual  function. 

The  patient  states  that  she  had  none  of  the  usual  chil- 
dren's diseases.  She  also  says  that  she  had  an  operation  a 
year  ago  for  "stretching." 

When  a  patient  begins  to  menstruate  at  18,  not  having 

355 


356  THE   ENDOCRINES 

had  any  of  the  diseases  of  childhood,  you  have  to  think  of  sim- 
ply internal  physical  and  endocrine  conditions  that  are  not 
produced  by  accidental  factors.  Don't  forget  that  measles, 
and  scarlatina,  and  diphtheria,  and  mumps  in  particular  have 
a  marked  effect  in  influencing  the  endocrine  glands ;  and  don't 
forget  that  many  persons  do  not  have  these  children's  diseases, 
or,  if  they  do,  have  them  very  lightly, — just  because  their 
endocrines  are  protecting  them.  You  know  the  Schick  test 
shows  that  some  persons  are  immune  to  diphtheria.  You 
know  that  diphtheria  affects  the  adrenals  badly,  and  those 
children  whose  adrenals  are  badly  attacked  do  worse.  If  the 
individual  has  an  influenza  pneumonia,  it  hits  the  endocrines 
that  are  protecting  him,  whether  the  adrenals  or  the  thyroid 
or  pituitary,  etc.,  if  they  come  up  to  the  mark,  it  is  all  right; 
if  not,  the  patient  dies.  The  time  will  come  when  we  shall 
treat  these  patients  with  hypodermics  of  endocrine  extract, — 
but  not  the  adrenal  medulla  always ;  it  is  the  cortex  you  often 
need,  which  is  just  as  valuable.  For  years  I  have  discontinued 
the  routine  use  of  adrenalin,  for  it  hurst  more  patients  than  it 
helps ;  it  is  not  the  adrenal  medulla  you  want  in  many  cases, 
but  the  cortex. 

On  examining  this  patient  we  find  a  fairly  normal  posi- 
tion and  size  of  the  uterus.  She  has  on  both  sides  cystic 
ovaries,  and  they  are  cystic  to  such  a  degree  that  the  outer 
surface  is  nodular  like  this.  You  may  have  a  cystic  ovary  with 
the  outer  surface  perfectly  smooth  and  regular,  or  you  may 
have  an  irregularly  shaped  surface,  feeling  like  little  tubercles. 
Both  of  this  patient's  ovaries  are  affected  in  that  way.  It  is 
quite  probable  that  she  does  not  throw  out  ova.  We  must 
await  the  examination  for  spermatozoa  before  we  can  go  fur- 
ther with  this  case.  Some  day  you  will  have  a  great  respect  for 
cystic  ovaries,  and  more  particularly  for  the  various  kinds  of 
cystic  ovaries.  I  told  you  I  would  talk  to  you  this  morning  on 
endocrines.  I  am  not  going  to  talk  about  Basedow's  disease, 
nor  exophthalmic  goitre,  nor  any  of  the  various  forms  of  Base- 
dow's disease,  toxic  or  otherwise.     I  win  just  mention  hyper- 


CLINICS  357 

thyroidism,  which  is  as  good  a  name  for  over-activity  of  the 
thyroid  as  you  could  wish  to  have. 

You  know  the  pituitary  gland  has  an  anterior  and  a  pos- 
terior lobe,  and  there  is  a  middle  area  too,  concerning  which 
we  are  not  definitely  informed.  You  know  that  the  adrenal 
has  a  cortex,  to  which  very  little  attention  has  been  paid,  but 
to  which  I  have  been  paying  a  good  deal  of  attention  with  the 
most  interesting  and  promising  results. 

You  know  that  in  the  ovary  you  have  the  interstitial 
portion,  to  which  little  attention  has  been  paid,  but  to  which 
I  have  been  paying  attention  for  years.  It  is  the  part  between 
the  follicles.  You  know  that  we  have  the  follicular  ovary,  and 
so  you  see  three  different  endocrine  glands,  at  least,  com- 
posed of  two  distinct  anatomical  parts  with  distinct  secre- 
tions, having  absolutely  different  effects. 

We  have  been  working  along  with  the  thyroid  for  years 
asleep  to  the  fact  that  the  thyroid  has  also  two  secretions,  the 
interstitial  and  the  acinous  or  glandular,  and  that  is  where 
we  expect  in  the  next  few  months  to  get  a  still  more  definite 
distinction  than  the  general  ones  we  have  had  heretofore. 

I  am  not  saying  anything  today  about  the  parathyroids, 
nor  the  pineal  gland,  nor  the  spleen,  etc.,  we  are  just  going  to 
devote  our  attention  to  these  four  glands  for  the  time  being, 
and  as  I  talk  to  you  I  will  talk  about  the  thyroid  in  its  entirety, 
for  the  finer  division  has  yet  to  be  worked  out  more  definitely. 

The  thyroid  is  as  essential  to  the  development  of  the  body 
and  mind  and  the  sex  organs  as  any  of  the  other  glands  of  the 
body.  You  know  the  signs  of  thyroid  cretinism ;  you  know  how 
the  mind,  the  brain,  fails  to  develop;  you  know  the  signs  of  the 
total  absence  of  the  thyroid,  and  you  know  the  signs  of  in- 
fantile and  adult  myxoedema.  You  also  know  the  so-called 
signs  of  Basedow's  disease,  and  as  you  compare  the  diseases 
called  myxoedema  and  hyperthyroidism  you  see  that  they  are 
totally  opposite.  With  too  much  thyroid  you  will  get  a  rapid 
pulse ;  too  little  will  give  a  slow  pulse ;  while  too  much  will 
give  a  moist  skin ;  too  little  will  give  a  dry,  scaly  skin ;  while 
thyroid  plus  will  give  too  much   activity  and  stimulate  the 


358  THE    ENDOCRINES 

brain  so  that  the  patient  talks  or  is  excitable;  with  thyroid 
minus,  it  is  just  the  opposite.  The  same  holds  true  with 
metabolism, — with  thyroid  plus  it  is  exaggerated ;  with  thyroid 
minus  it  is  under  normal.  All  the  conditions  that  come  from 
thyroid  plus  will  be  exactly  the  opposite  with  thyroid  minus. 

Now  take  the  element  of  talking.  Of  course  it  depends 
upon  what  kind  of  brain  it  is  that  controls  the  talking.  If  it 
is  a  brain  like  Roosevelt's  the  talking  and  thinking  is  very 
much  worth  while;  but  the  man  or  woman  who  has  not  been 
educated  or  has  not  a  brain  that  acts  properly  or  that  is  not 
acted  upon  properly  by  other  glands,  may  talk  as  much  but  the 
output  will  differ  very  much  in  quality.  Now  Roosevelt  had 
a  wonderful  thyroid  and  adrenals  and  a  very  wonderful  an- 
terior pituitary.  He  had  the  paternal  instinct  in  the  maternal 
way,  and  that  shows  that  he  had  a  good  post,  pituitary.  You 
can  tell  that  from  his  letters  to  his  children. 

Now  the  question  is :  thyroid  disease  of  all  grades  is  eight 
to  ten  times  more  frequent  in  women  than  in  men ;  that  refers 
more  particularly  to  the  greater  division,  such  as  the  real  oper- 
ative thyroid  cases.  The  thyroid  will  not  be  operated  upon  so 
much  in  the  next  few  years  as  it  has  been  in  the  last  few 
years, — neither  for  that  matter  will  fibroids.  Why  do  women 
suffer  from  hyperthyroidism  so  much  more  frequently  than  do 
men?  A  woman  has  ovaries  and  a  man  has  the  male  gonads 
or  testes.  Outside  of  that  and  the  mammary  they  have  the 
same  glands,  although  their  division  is  totally  different. 

The  anterior  lobe  of  the  pituitary  does  more  work  in  a  man 
than  in  a  woman ;  the  interstitial  part  of  the  gonad  which  is  in 
the  testis,  the  cells  of  Leydig,  does  more  work  in  the  man  than 
in  the  woman,  and  a  certain  part  of  the  thyroid  does  much  more 
work  in  man  than  in  woman.  The  posterior  pituitary  lobe 
does  more  work  in  a  woman  than  in  a  man;  of  the  adrenals, 
the  medulla  does  more  work  in  a  woman  than  in  a  man;  the 
follicular  part  of  the  ovary  does  more  work  In  a  woman  than 
in  a  man;  and  a  certain  part  of  the  thyroid  does  much  more 
work  in  a  woman  than  in  a  man ;  so  that  the  anterior  pituitary, 
adrenal  cortex,  interstitial  gonads  and  interstitial  thyroid  are 


CLINICS  359 

male  glands ;  the  posterior  pituitary,  the  adrenal  medulla, — the 
follicular  part  of  the  ovary,  and  a  certain  glandular  part  of  the 
thyroid  are  female  glands.  Any  man  who  has  more  of  the 
female  part  of  his  glands  developed  than  is  normal  to  man,  to 
that  degree  does  he  tend  to  go  over  to  the  woman  side  in  ex- 
ternal type,  characteristics,  tastes,  etc., — so  that  every  one  of 
us  is  the  expression  in  looks,  appearance,  action,  and  behavior 
of  the  action  of  the  little  glands  that  are  furnishing  us  and  have 
furnished  us  all  our  lives  with  hormones,  and  those  of  us  who 
are  good  do  not  have  very  much  reason  to  be  proud  of  it,  and 
those  of  us  who  are  weak  have  no  reason  to  be  too  depressed 
about  it, — for  what  we  are  has  been  given  to  us  by  our  fathers 
and  mothers,  and  influenced  by  our  environment,  by  infections, 
etc.,  etc.. 

The  law  cannot  as  yet,  however,  take  that  into  considera- 
tion; for  our  own  self-protection  limits  must  be  established 
beyond  which  no  one  can  go  without  restriction,  for  the  benefit 
of  society, — but  some  day  we  will  be  much  more  charitable 
toward  the  weak  and  the  criminal  and  not  waste  too  much  of 
our  praise  and  idolatry  on  those  who  have  been  good  and 
great. 

Now  why  are  the  thyroid  diseases  so  much  more  com- 
mon in  woman  than  in  man  ?    What  is  the  answer  ? 

It  is  because  of  the  ovaries.  Logically,  it  can  be  nothing 
else.  If  the  other  glands  are  relatively  the  same  except  as  to 
proportionate  development,  and  the  male  has  the  testes  and 
the  woman  has  the  ovaries,  it  is  logical  that  the  primary  con- 
dition must  rest  in  the  ovaries, — and  that  is  why  gyne- 
cologists have  always  been  rather  sympathetic  toward  these 
hyperthyroid  or  hypothyroid  states,  and  that  is  why  they  see 
them  so  often  and  see  them  in  a  form  and  at  a  time  when  no 
one  else  sees  them.  If  the  condition  is  bad  enough  to  be  a 
Basedow's  disease,  the  patient  may  go  to  a  physician  or  sur- 
geon; if  it  is  very  slight,  she  goes  to  no  one;  but  if  she  is 
nervous  and  upset,  she  immediately  thinks,  as  all  women  do, 
that  something  down  In  the  pelvis  Is  responsible  for  her 
nervousness  and  so  she  goes  to  a  specialist,  and  in  that  way 


360  THE    ZXDOCRIXES 

these  I'requenriy  uniecognized  latent  hypertlr.Toid  cases  come 
to  the  gynecologists. 

I  have  just  now  in  my  bi-manual  examination  put  my 
finger  on  that  little  recognized  but  really  most  important  little 
cystic  OTary.  A\Tien  you  have  a  cystic  o\"ary,  you  have  follicles 
which  have  never  ruptured,  and  if  a  follicle  does  not  rupture 
then  an  ^g-  cannot  come  out  and  the  patient  is  sterile.  Is  that 
right? 

Then  you  have  in  the  o'^'ar}-  corpus  luteum  rests  and 
corpus  luteum  cysts.  Xow,  we  are  getting  warmer  all  the  time. 
The  ovaries  act  in  every  little  girl  from  the  day  she  is  bom, 
just  the  same  as  the  pituitary  does,  just  the  same  as  the  thy- 
roid does,  just  the  same  as  the  adrenals  do,  just  the  same  as 
the  parathyroids  do,  just  the  same  as  do  all  the  other  glands. — 
but  we  did  not  know  it,  and  why  not  ?  Because  we  have  been 
acxnistomed  to  think  of  menstruation  as  the  only  evidence  of 
ovarian  activity;  but  menstruation  is  not  ovarian  activit}- 
alone.  If  these  ovaries  were  not  helped  by  the  pituitary,  by  the 
thyroid,  by  the  adrenals,  etc.,  girls  could  not  menstruate ;  so 
when  the  twelfth,  thirteenth,  or  fourteenth  year  does  come. 
each  menstruation  is  initiated  b}-  the  ovaries,  but  with  that 
there  must  be  the  help  of  the  other  glands ;  and  if  that  girl  has 
a  posterior  pituitary  minus  sufficiently  inadequate  to  give  her 
what  we  call  a  dystrophia  adiposo  genitalis,  then  the  uterus 
and  the  ovaries  do  not  develop  and  she  does  not  menstruate, 
and  you  can  give  her  all  the  ovarian  extract  and  other  com- 
binations possible  and  you  will  get  no  response  unless  you 
g^'ve  the  right  ones.  Or  supposing-  3-ou  have  a  thyroid  anomaly : 
:hr  : varies  immediateh^  respond  and  are  often  injured;  when 
:he  :h3rroid  is  overactive  it  may  injure  or  depress  the  ovary. 
Ir.  ::r.tr  words,  dependent  as  the  ovar}-  is  on  th^Toid  stimnla- 
t::n  :  t  -'r.'—o-A  and  the  ovary  are  at  the  same  time  at  the 
f^y-v/z  z.-.ii  ::  the  balance,  and  while  each  stimulates  the 
other,  an  excess  cf  either  over-stimulates  the  other:  and  with 
ar.;-  :  ■  :  r'^ri-  : r  ^arts  of  glands  which  are  related  to  each 
c:''.rr  :r.  :'  t  itircc  zi  "You  tickle  me  and  I  tickle  you,"  if  one 
c:  :r.t"   r^:-  :::  strong  it  inhibits  the  other,  and  vice-versa. 


CLINICS  361 

You  and  I  might  be  playing  at  wrestling, — or  little  kit- 
tens, or  bears,  or  rabbits  may  be  playing;  and  the  play  of 
one  stimulates  the  other.  I  may  be  very  much  stronger  than 
you,  but  if  I  modify  my  muscular  activity  I  will  not  hurt  you; 
but  if  I  get  away  from  the  spirit  of  play  and  exert  my  full 
power,  down  you  go ;  or  if  we  happen  to  be  unevenly  matched 
and  the  other  one  gets  angry  and  is  (then)  more  powerful  than 
I  am,  down  I  go, — but  in  the  normal  play  or  activity  each 
stimulates  the  other  to  the  proper  degree.  Any  two  glands  that 
act  upon  each  other  must  have  a  balance  maintained  between 
them  in  every  normal  economy,  if  they  are  opposite  in  their 
actions ;  if  the  anterior  pituitary  is  active,  it  stimulates  the  post, 
pituitary;  if  the  anterior  increases  too  much,  then  it  begins  to 
diminish  the  activity  of  the  posterior;  if  the  posterior  begins 
to  increase  too  much,  it  diminishes  the  activity  of  the  anterior. 

Take  the  element  of  curettage.  Why  will  a  woman,  if 
'curetted  too  thoroughly,  cease  menstruation?  Especially  be- 
fore menstruation  the  endometrium  gives  out  a  secretion  which 
stimulates  the  ovaries.  Within  three  days  of  menstruation 
the  decidua  gets  still  thicker  and  further  stimulates  the  ovary ; 
but  if  you  curette  the  endometrium  entirely  away  the  ovary, 
missing  the  stimulation,  may  stop  its  normal  function  or 
the  corpus  luteum  may  not  regress,  and  you  may  have  a  dif- 
ficult task  to  get  the  menstruation  back. 

Now,  about  prescribing  ovarian  extract  for  this  patient. 
Ever  since  I  began  the  use  of  ovarian  extract  I  have  prescribed 
the  whole  gland,  and  I  have  been  doing  that  for  twenty-two 
years ;  and  in  my  earlier  years  I  always  prescribed  Merck's 
ovarian  extract, — which  w^as  imported  until  our  own  local 
drug  houses  began  to  make  it  right.  France,  Italy  and  other 
European  countries  began  making  these  gland  extracts  right 
before  we  did.  I  don't  think  in  my  whole  life  I  have  written 
a  prescription  for  corpus  luteum  once  where  I  have  written 
ovarian  extract  fifty  times.  And  why  not?  Why  have  I  al- 
v^^'ays  said  that  corpus  luteum  is  not  the  drug  or  secretion 
for  the  cases  for  which  I  am  giving  ovarian  extract?  Be- 
cause the  true  corpus  luteum  only  develops  actually  where  and 


362  THE    ENDOCRINES 

when  the  patient  is  pregnant.  While  there  is  a  luteum  change 
in  the  inner  Hning  of  the  ruptured  foHicle  this  grows  more 
after  pregnancy  than  when  there  is  no  pregnancy,  and  it  must 
be  something  different  from  the  ordinary  ovarian  extract. 
Why  does  nature  make  the  corpus  luteum  grow  during  preg- 
nancy? It  undoubtedly  exerts  a  trophic  influence  on  the  en- 
dometrium, it  gives  the  endometrium  something  to  help  re- 
strain the  trophoblast  cells  of  which  I  spoke  the  other  day. 

But  the  next  important  act  of  the  corpus  luteum  is  that 
it  inhibits  ovulation ;  in  other  words,  nature  does  not  want  the 
ovaries  to  ovulate  during  pregnancy.  It  is  waste  of  eggs  in 
the  first  place,  and  starts  that  stimulation  to  menstruation 
which  nature  does  not  want;  and  so  the  C.  L.  must  have  an 
action  totally  opposite  to  that  of  the  ordinary  ovarian  secre- 
tion. I  have  given  C.  L,  to  inhibit  menstruation ;  I  have  given 
it  for  menorrhagia.  Corpus  luteum  stimulates  the  thyroid  be- 
fore each  menstruation  and  during  menstruation  and  in  preg- 
nancy, especially,  is  supposed  to  inhibit  the  posterior  pituitary. 

Now  you  have  your  cystic  ovary,  and  your  corpus  luteum 
rests,  and  your  cystic  ovary  and  your  corpus  luteum  cysts  are 
something  you  don't  find  in  a  man.  You  may  say  he  has  the 
cells  of  Leydig ;  you  may  say  he  has  his  adrenals ;  but  he  has 
not  the  corpus  luteum,  and  the  only  two  things  he  has  not 
that  the  woman  has  are  the  corpus  luteum  and  the  placenta. 
Therefore,  if  you  follow  this  thing  out  with  an  eye  to  logic 
you  will  see  that  only  two  things  can  be  responsible,  the 
corpus  luteum  and  the  placenta.  But  thousands  of  women 
have  hyperthyroidism  without  being  pregnant.  Put  your  finger 
on  the  corpus  luteum.  It  is  the  corpus  luteum  that  gives  the 
woman  the  tendency  to  hyperthyroidism ;  and  it  is  the  retained 
corpus  luteum  in  the  child  that  may  cause  is  to  be  nervous,  for 
the  ovaries  are  working  in  the  little  girl  of  five  to  nine  years  of 
age;  and  if  you  watch  your  little  girl,  or  your  patient's  little 
girl,  you  will  find  In  many  a  child,  just  as  you  find  -In  the  adult 
woman,  the  cyclic  premenstrual  phenomena  If  you  look  for 
them.  A  little  girl  will  go  along  perfectly  well,  normal  and 
happy  and  jolly;  then  for  three  or  four  days  will  have  sleep- 


CLINICS  363 

less  nights,  will  be  excitable,  incorrigible,  etc.,  and  the  parents 
discipline  the  child.  Then  again  the  child  is  perfectly  normal 
for  another  twenty  odd  days,  and  then  comes  another  period 
of  irritability,  etc.  Has  it  ever  entered  into  the  minds  of  the 
parents  to  realize  that  that  comes  along  every  four  weeks? 
Nio.  Have  we  ever  told  them  that  it  does?  No,  for  we  have 
never  thought  of  it  ourselves.  Just  as  often  as  you  find  the 
premenstrual  phenomena  in  the  adult  woman,  just  so  often 
may  you  find  them  in  the  little  girl  if  you  look  for  them.  Hence 
many  of  us  have  been  unjust  and  impatient  with  such  little 
girls. 

You  know  how  follicles  break,  how  follicles  fill  w4th  blood 
and  regress.  In  most  ovaries  at  operation  you  see  one  or  two 
corpus  luteus  rests  remaining;  then  you  also  see  many  un- 
broken cysts.  For  years  I  have  operated  on  certain  sterility 
cases  by  laparotomy,  removing  from  the  ovaries  cysts  and 
corpora  lutea,  etc.,  for  so  long  as  they  are  there  many  a  patient 
will  not  ovulate,  and  so  long  as  corpora  lutea  are  there  they 
are  hurting  her  thyroid  and  making  it  sensitive. 

Now,  of  all  the  things  on  which  I  have  laid  stress  for 
years,  one  of  the  most  important  is  this :  When  you  take  a 
patient's  history,  ask  her  as  much  as  you  like  about  how  old 
she  was  when  she  commenced  to  menstruate,  how  menstrua- 
tion came  on,  etc.,  ask  her  what  you  like,  but  be  sure  to  ask 
her  this  one  small  question :  "How  many  days  before  you 
menstruate  can  you  tell  that  you  are  going  to  be  unwell?"  It 
is  the  simplest  question  to  ask,  but  there  is  not  a  key  that 
opens  to  you  as  much  knowledge  of  the  patient's  state  as  that. 
If  she  says  that  she  does  not  know  until  the  blood  comes, — 
write  on  your  chart:  "Good  endocrines,"  and  write  it  in  red 
ink.  If  she  tells  you  that  a  week  before  such  menstruation 
her  breasts  become  full  and  she  has  a  little  pain, — that  is  some- 
thing. But  if  she  says  that  a  week  before  her  menstruation 
she  is  excitable,  restless,  "crazy";  that  she  slaps  her  children, 
though  she  does  not  at  other  times ;  that  she  quarrels  with  her 
husband,  which  she  does  not  at  other  times, — then  write  on 
your  card  that  something  is  wrong  with  some  of  the  endocrines. 


364  THE    ENDOCRINES 

Could  you  ask  for  anything  more  clear  ?  That  is  why  in 
gynecology  we  have  gone  on  to  this  endocrine  treatment,  be- 
cause we  have  the  symptoms  that  many  doctors  do  not  ask 
for, — and  I  am  afraid  that  many  gynecologists  do  not .  That  is 
the  time  to  find  out  which  of  the  glands  are  at  fault  in  produc- 
ing the  symptoms.  The  one  that  is  frequently  at  fault, — 
not  alone, — is  the  thyroid.  You  will  have  patients  who  are 
hypothyroid  at  all  other  times, — will  have  cold  hands,  dry 
fingers,  dry  skin;  are  tired  mentally,  languid, — all  the  signs 
of  hypothyrodiism,  who  five  or  seven  days  before  menstrua- 
tion show  hyperthyroidism.  Some  have  a  hyperadrenalism 
before  each  menstruation;  some  a  hyperpituitarism,  etc.  So 
there  is  not  a  play  or  juggle  of  the  endocrines  in  one  patient 
that  you  don't  find  the  like  or  a  different  one  in  another. 

And  you  will  find  the  same  things  in  the  girl  at  her 
entrance  into  the  menstrual  life  at  thirteen  to  fifteen.  You  will 
find  palpitations,  tachycardia,  excitability,  nervousness,  etc., 
etc*  Some  girls  have  to  be  taken  out  of  school.  It  is  hyper- 
thyroidism, or  hyperadrenalism  or  hyperpituitarism.  I  don't 
think  it  is  hyperthyroidism  alone.  If  you  have  a  bad  combina- 
tion, you  have  a  fearful,  nervous,  frightened  sort  of  person, 
whether  it  is  a  child,  or  a  girl  of  the  adolescent  age,  or  one 
going  to  get  married,  or  a  woman  at  the  change  of  life.  Think 
what  you  can  do  with  them !  And  while  I  am  telling  you  about 
hyperthyroidism,  think  of  every  patient  from  the  standpoint 
of  the  ten  or  fourteen  glands  in  the  body.  Don't  give  all  con- 
ditions a  name.  Why  should  you  call  it  hyperthyroidism,  until 
you  are  sure  it  is  that  only;  it  may  be  alternately  hyper  or 
hypothyroidism ;  it  may  be  hyper  or  hypopituitarism, — anterior 
or  posterior.  Forget  the  name  of  the  disease  and  put  down  on 
your  chart  the  glands  which  are  hyper  or  hypo.  As  I  said  to 
you  the  other  day,  I  believe  in  the  future  history  cards  will 
be  written  like  music  sheets, — above  the  heavy  line  of  nor- 
mality are  to  be  written  the  glands  which  are  plus,  and  below 
the  lines  the  glands  which  are  minus.  Then,  instead  of  being 
introduced  to  Mrs.  So  and  So,  you  will  show  me  a  card,  and  I 
will  say :     Ovaries,  interstitial,  normal ;  ovaries,  follicular  ap- 


CLINICS  365 

paratus,  hyper ;  adrenal  cortex  minus ;  adrenal  medulla  minus ; 
or  pituitary, — posterior  or  anterior, — plus  or  minus,  etc., — 
and  I  can  almost  tell  you  what  she  looks  like,  how  she  acts, — 
if  what  you  showed  me  is  correct, — and  can  tell  you  how  to 
treat  her. 

So  with  children.  They  do  go  through  their  premenstrual 
cyclic  phenomena  long  before  they  menstruate,  and  it  is  a  very 
important  thought.  A  like  thought  applies  as  well  to  boys  as 
to  girls,  but  to  girls  particularly. 

Then  when  you  come  to  the  change  of  life  period,  the 
glands  are  going  back  to  the  same  stage  or  condition  as  be- 
fore menstruation  was  established ;  and  as  the  girl  entered  the 
active  glandular  period  and  thereafter  was  or  was  not  affected 
by  the  various  inter-current  conditions, — such  as  infectious 
diseases,  pregnancy,  labor,  etc.,  etc.,  so  the  patient  goes  out  of 
the  stage  of  glandular  activity  with  relatively  the  same  degree 
of  hyper  or  hypo,  or  normal  conditions  with  which  she  entered 
into  it.  That  is  why  the  family  history  is  so  important;  in 
some  families  they  all  start  to  menstruate  late;  in  others,  all 
start  early,  etc.  Some  families  never  have  any  upsets ;  others 
show  a  history  of  frequent  upsets.  What  do  psychological 
and  psychic  changes  mean  at  the  menopause  age?  Nothing 
more  than  a  psychic  upset,  as  at  any  other  period.  Remember, 
all  psychic  upsets  are  the  result  of  endocrine  activity  unless 
produced  by  trauma,  or  tuberculosis,  or  syphilis,  etc., — and 
there  is  not  one  of  you  sitting  here  that  does  not  possess  a 
certain  amount  of  instinct  or  emotion  which,  if  exaggerated 
sufficiently,  would  constitute  a  psychosis.  The  very  interest, 
positiveness,  and  enthusiasm  with  which  I  am  talking  to  you 
might  be,  if  exaggerated  enough  and  without  proper  cerebra- 
tion and  control,  a  very  severe  psychosis.  That  is  all  there 
is  to  any  psychosis.  It  is  an  exaggeration  of  an  emotion, — 
the  exaggeration  of  fear,  or  of  the  sex  idea  which  may  be  the 
dominating  thought  and  talk  of  patients  with  psychosis.  The 
instinct  of  being  with  other  people,  gregariousness,  and  of 
being  afraid  of  being  alone,  if  exaggerated  is  a  form  of  psy- 
chosis.   The  idea  of  wanting  to  be  alone  and  away  from  others 


366  THE    ENDOCRINES 

may  be  hugely  exaggerated.  The  difference  between  a  recluse 
and  a  person  in  a  sanatorium  is  simply  one  of  degree ;  the  dif- 
ference between  a  high  grade  moron  and  a  feebleminded  per- 
son is  only  one  of  degree. 

So  that  a  study  of  the  climacteric  period,  with  the  re- 
adjustment of  the  endocrines  of  a  patient  who  is  thirty  years 
older  than  when  she  began  to  menstruate  and  with  a  resistance 
therefore  less  than  before,  because  of  all  the  intercurrent 
changes  produced  by  intercurrent  physical  and  pathological 
processes,  is  full  of  interest  and  value;  but  the  period  during 
which  a  girl  goes  into  the  menstrual  cycle  is  just  as  danger- 
ous for  her,  for  that  is  the  period  at  which  dementia  precox 
develops,  and  perhaps  five  years  from  now  we  will  have  no 
more  dementia  percox,  for  we  will  have  learned  to  recognize 
the  early  threat  and  treat  these  cases  long  before  they  develop 
the  symptoms.  Last  year  in  the  Journal  of  the  American 
Medical  Association  was  a  report  from  one  of  the  hospitals 
in  Boston  of  100  cases  of  psychosis,  that  had  been  admitted 
within  a  few  days  or  weeks  after  an  attack  of  influenza, — some 
of  the  cases  having  had  pneumonia,  others  not.  Among  these 
were  50  or  60  cases  of  dementia  precox  and  manic  depressive, 
etc.  Would  any  one  mean  to  tell  me  that  those  cases  were 
due  only  to  the  influenza  bacillus  and  toxins  acting  directly  on 
the  cerebrum  ?  No,  the  toxins  affected  the  glands  in  the  latent 
cases  and  rushed  them  on  the  explosion  of  the  psychosis.  And 
what  is  the  sleeping  sickness  or  encephalitis  lethargica?  You 
may  have  as  much  injury  in  the  cerebral  cells  as  you  like,  but  a 
basic  element  is  the  pituitary  gland  that  is  affected  so  that 
the  patient  may  go  into  hibernation. 

Just  the  same  when  you  go  to  sleep.  Your  glands  go  to 
sleep;  but  if  your  glands  do  not  go  to  sleep  you  have  dreams 
or  wakefulness,  and  your  dreams  or  your  waking  thoughts  are' 
governed  by  the  gland  or  glands  that  are  over-excited ;  and  the 
glands  that  give  the  most  trouble  are  the  thyroid  and  adrenals 
and  pituitary.  If  you  read  or  drink  coffee,  and  stimulate  your 
thyroid  and  the  pituitary,  then  you  may  lie  awake  for  hours, 
and  you  cannot  sleep,  for  your  thyroid  is  not  asleep;  and  if 


CLINICS  367 

you  get  in  a  terrible  fit  of  anger  before  you  go  to  bed,  and 
your  adrenal  gland  is  especially  active  or  stimulated,  you  can- 
not go  to  sleep,  your  adrenal  endocrine  is  stimulating  the 
brain.  So  what  you  think  when  you  are  awake  and  trying 
to  sleep  is  an  important  indication  for  the  doctor.  If  it  is 
a  dream  of  making  a  speech  or  doing  something  philosophical, 
that  is  governed  by  your  anterior  pituitary  lobe;  if  you  are 
dreaming  because  of  adrenal  cortex  activity,  you  are  doing 
something  pugnacious;  if  your  adrenal  medulla  is  over- 
stimulated,  you  are  having  dreams  of  fears ;  if  it  is  a  sex  gland 
that  is  causing  the  stimulation  or  keeping  you  awake,  then 
you  are  dreaming  or  thinking  along  those  lines.  Take  a  pencil 
and  make  a  big  mark  around  the  word  Freud.  Avoid  the 
application  of  the  Freudian  doctrines.  If  anything  in  medicine 
has  brought  disquiet  to  the  doctors  and  unhappiness  to  the 
patient,  it  is  the  Freudian  doctrine.  The  individual  who  thinks 
certain  thoughts  in  the  day  time  and  who  dreams  of  them  when 
he  is  asleep  is  often  no  more  responsible  for  the  type  of  his 
dream  than  I  am  for  what  the  weather  will  be  tomorrow. 

Post-Graduate  Hospital 
December  16,  1919 

This  patient  is  41  years  old.  She  has  had  five  children, 
the  last  six  years  ago.  She  has  had  three  miscarriages,  5,  4, 
and  2  years  ago.  The  last  one  was  at  the  5th  month.  Her 
menstruation  has  been  irregular  for  the  last  few  months,  com- 
mg  every  three  to  eight  weeks.  She  complains  of  pelvic  pain, 
'  ^s  had  headaches  and  dizziness,  and  attacks  of  palpitation. 

It  is  for  us  to  determine  w^hether  this  patient  has  a  local 
condition  responsible  for  the  pain  and  what  relation,  if  any, 
the  local  pelvic  condition  has  to  her  general  state. 

Looking  at  the  history,  especially  in  view  of  her  men- 
struation which  has  been  irregular, — sometimes  every  three 
and  sometimes  every  eight  weeks, — it  looks  very  much  as  if 
she  were  ready  to  enter  into  the  so-called  change  of  life, — the 
climacterium.  However,  we  are  here  confronted  with  the 
problem  of  reflex  influence, — the  old  bugbear  of  gynecology. 


368  THE    ENDOCRINES 

that  trend  in  our  specialty  which  has  done  so  much  harm;  the 
incHnation  to  say  that  anything  wrong  in  the  pelvis  is  by  re- 
flex action  responsible  for  everything  of  which  the  patient 
complains. 

In  many  of  these  cases  you  find  the  uterus  enlarged 
and  displaced, — letroflexed  or  retroverted,  which  are  not  the 
normal  positions;  yet  while  they  have  very  much  to  do  with 
the  patient's  general  state, — while  they  may  influence  her  gen- 
eral health  very  much, — it  is  not  right  for  us  to  say  that  reflex 
influence  explains  everything.  Patients  at  this  stage  may  have 
various  gastric  disturbances ;  they  are  likely  to  have  gallstones, 
or  peptic  or  duodenal  ulcers;  if  they  suffer  from  headaches 
that  may  be  due  to  a  condition  depending  on  congestion;  it 
may  be  dependent  on  a  renal  condition,  or  on  the  endocrines. 

This  patient  talks  very  much  as  if  she  had  a  pharyngeal 
irritation.  We  know  enough  about  the  invasion  of  the  sinuses 
to  know  that  many  an  intractable  headache  m,ay  be  dependent 
on  that  state  and  have  nothing  to  do  with  the  metabolism  of  the 
body  in  general.  So  it  is  an  old  hobby  of  mine,  and  I  have 
been  more  and  more  confirmed  in  my  opinion  as  I  grow  older, 
that  it  is  a  very  serious  mistake  to  refer  to  reflex  channels 
many  symptoms  and  conditions  supposedly  produced  by  altera- 
tions and  changes  in  the  pelvic  tract. 

Our  problem  here  is  to  determine  whether  what  we  find 
on  pelvic  examination  explains  the  symptoms  for  which  she 
comes  to  us,  or  whether  we  are  to  be  guided  in  our  diagnosis 
of  the  symptoms  by  the  fact  that  she  appears  to  be  ready  to 
enter  the  climacteric  state. 

(Examining.)  You  see  she  makes  more  fuss  about  the 
left  than  the  right  side.  We  find  a  cervix  that  is  badly  lac- 
erated on  both  sides,  a  uterus  that  is  decidedly  retroverted 
and  almost  retroflexed,  and  which  is  enlarged.  The  enlarge- 
ment of  the  uterus  need  not  surprise  us  for  the  patient  has  had 
three  miscarriages  in  the  last  five  years.  After  miscarriages 
we  frequently  find  a  subinvolution  persisting,  because  the  sim- 
ple emptying  of  the  uterus  of  its  own  accord  or  cleaning  of 
the  uterus  by  curettage  does  not  constitute  all  that  should  be 


CLINICS  369 

done  to  bring  the  uterus  lack  by  normal  involution  to  its  nor- 
mal size.  Therefore  after  miscarriages,  whether  a  curettage 
is  done  or  not,  the  patient  should  be  given  for  a  long  period 
of  time  some  of  the  ergot  or  mammary  extract  preparations 
until  the  uterus  is  of  the  normal  size;  and  now  that  we  know 
the  value  of  mammary  extract,  we  find  it  is  often  better  than 
the  ergot  preparations  for  bringing  about  a  normal  involution. 

That  is  simply  repeating  what  I  have  said  so  many  times. 
If  nature  produces  involution  by  the  aid  of  nursing;  and  if 
nursing  brings  about  involution  by  the  extract  of  the  mam- 
mary gland,  why  should  not  we  use  the  same  drug  when  we 
want  to  produce  involution  ?  So  there  is  no  objection  to  giving 
both  ergot  and  mammary  extract;  for  instance,  you  may  give 
ergotin  gr.  1-2  and  7  grains  of  mammary  extract  in  a  capsule; 
and  give  these  two  drugs  three  times  a  day  for  many  weeks, 
(Instructs  Dr.  Tai  in  making  examination  with  speculum.) 
Nbw  we  will  paint  the  cervix  with  3y2  per  cent,  tincture  of 
iodine.  On  using  the  sound  we  find  that  the  uterus  is  nearly 
an  inch  longer  than  normal,  and  the  sound  shows  the  position 
to  be  retroversion  with  a  tendency  to  retroflexion, — and  an 
enlarged  uterus. 

Now  I  will  ask  you  what  has  the  retroversio-flexio  and 
what  has  the  laceration  of  the  cervix  to  do  with  this  patient's 
general  symptoms?  What  is  the  relationship?  Are  her  head- 
aches and  the  dizziness  of  which  she  complains,  the  palpita- 
tion and  the  irregularity  of  the  menstruation  to  be  exjDlained  by 
the  laceration  of  the  cervix?  You  will  find  that  in  past  years, 
and  even  today,  there  is  a  persistent  notion  in  the  minds  of 
hundreds  of  practitioners  that  a  lacerated  cervix  by  reflex  is 
responsible  for  any  number  of  annoyances  from  the  top  of  the 
head  to  the  soles  of  the  feet.  They  thus  explain  headaches, 
dizziness,  nausea,  vomiting,  indigestion,  tachycardia,  sleep- 
lessness,— all  the  annoyances  that  are  included  in  what  I  con- 
sider symptoms  peculiar  to  the  climacterium. 

So  far  as  this  erroneous  teaching  goes,  in  this  patient 
there  is  no  relation  whatever  between  the  laceration  of  the 
cervix  and  any  of  the  symptoms  mentioned.     How  about  the 

24 


370  THE   ENDOCRINES 

retroversio-flexio  ?  Outside  of  the  local  annoyances  due  to 
the  displacement,  the  malposition  has  nothing  to  do  with  the 
symptoms  enumerated  in  this  patient's  history.  With  retro- 
versio-flexio, there  is  a  displacement  of  the  ovaries,  and  with 
ovaries  displaced  in  that  way,  or  with  ovaries  whose  circula- 
tion is  interfered  with,  or  with  ovaries  altered  in  their  char- 
acter by  inflammation  or  altered  as  to  their  secretory  char- 
acter by  cystic  changes,  you  may  have  annoying  constitutional 
symptoms, — not  because  there  is  a  reflex,  but  because  the 
secretory  activity  of  the  ovaries  is  interfered  with  and  may 
interfere  with  the  normal  activity  of  other  endocrines  on 
whose  normal  function  health  depends. 

Here  is  a  patient  who  is  menstruating  irregularly, — every 
three  to  eight  weeks, — and  it  is  for  us  to  determine  whether 
she  is  or  is  not  ready  to  go  into  the  so-called  climacterium, 
though  menopause  may  not  occur  for  six  months  or  even  years 
from  now.  This  wavering  between  periods  of  normal  action 
of  uterus  and  ovaries  and  the  period  when  their  activities 
cease  may  extend  over  years  of  time;  and  during  that  period 
of  time  the  patient's  endocrine  alteration  may  be  gradually 
going  on,  or  gradually  adapting  itself  to  what  is  going  to  be  the 
final  relation  when  menstruation  eventually  ceases.  We  know 
that  among  the  symptoms  of  the  climacterium  are  attacks  of 
dizziness,  palpitation,  periods  of  prolonged  sleeplessness,  pos- 
sibly headaches.  Then  there  are  variations  in  the  patient's 
metabolism,  in  the  patient's  mental  attitude;  the  psychic  state. 
As  I  said  before,  all  may  be  explained  only  on  the  basis  of  en- 
docrine alterations.  We  have  changes  in  the  ovaries,  changes 
in  the  secretion  of  the  thyroid,  of  the  suprarenals,  In  the  secre- 
tions of  the  pituitary, — and  these  changes  and  alterations  ac- 
count for  many  or  all  of  the  symptoms. 

The  most  frequent  condition  of  all  these  Is  one  that  in- 
volves the  thyroid  or  the  pituitary.  At  this  so-called  meno- 
pause period  some  patients  have  too  much  thyroid,  some  too 
little;  In  others  there  are  alterations  between  hyper  and  hypo- 
thyroidism. Now,  if  you  want  to  do  something  to  further 
your  medical  knowledge,  get  Cushlng's  work  on  the  pituitary 


CLINICS  371 

gland.  Although  it  is  mostly  surgical  and  although  some  of 
the  views  therein  are  not  absolutely  settled,  the  greatest  value 
of  the  book  will  be  the  following  of  the  photographs  you  will 
see  of  the  patients, — one  photograph  of  a  patient  in  her  or 
his  younger  days,  and  another  of  that  same  patient  during 
the  period  when  he  or  she  is  being  treated  for  the  specified 
disease.  You  will  be  astonished  to  note  the  changes  that  take 
place  in  these  patients, — changes,  the  nature  of  which  you 
will  learn  in  the  course  of  time  to  understand  and  value  at  a 
glance.  It  is  the  sam.e  as  if  I  had  today  the  photograph  of 
every  person  here  at  the  age  of  twenty  and  of  every  one  at 
his  or  her  present  age.  You  would  be  astonished  at  the  facial 
changes — if  you  looked  for  nothing  more, — at  the  physical 
changes;  and  of  course  if  we  could  analyze  these  properly  we 
might  be  amazed  at  the  psychic  and  mental  changes.  It  is 
well  enough  to  believe  that  the  air  we  breathe  and  the  food 
we  eat  affects  us.  The  lives  we  lead  affect  our  psychic  atti- 
tude, etc.,  but  after  all  these  things  do  not  cause  a  change  in 
bony  framework,  nor  a  change  in  the  shape  of  the  jaw  nor 
the  size  of  the  hands.  These  are  just  as  remarkable  or  worthy 
of  remark  as  the  growth  attained  at  21  or  22,  when  adolescents 
reach  the  adult  stage,  compared  with  the  state  of  the  child  at 
three  or  four.  The  two  most  noticeable  changes  that  you  will 
observe  in  these  pictures  are  the  changes  effected  mostly  by 
pituitary  alterations  and  those  that  are  due  to  the  thyroid  and 
adrenals.  The  thyroid  changes  will  not  be  so  marked  physical- 
ly,— I  mean  stature  and  the  bony  growth  of  the  face  will  not 
be  altered;  but  there  may  be  a  typical  appearance  of  exoph- 
thalmic goitre.  The  exophthalmos  attracts  your  attention,  but 
the  other  alterations  due  to  the  pituitary  are  the  most  noticeable ; 
and  you  will  readily  understand  some  of  these  when  you  remem- 
ber how  the  acromegalic  patient  looks.  There  are  thousands 
of  persons  with  such  changes  that  are  not  gross  enough  to  be 
called  acromegalic  but  can  be  detected  by  those  who  are  alert ; 
and  when  you  know  that  these  physical  changes  are  affected  by 
a  certain  lobe  of  the  pituitary  gland  (the  anterior  lobe)  you 
must  believe  that  these  glands  may  affect  the  patient's  mental 


372  THE   ENDOCRINES 

and  psychic  attitude  also.  That  is  why  I  say  that  during  this 
change  of  life  period,  when  the  physical  evidences  are  some- 
times pronounced,  it  is  easy  to  make  a  diagnosis;  but  when 
they  are  not  so  pronounced,  it  is  not  at  all  so  easy. 

The  results  of  this  patient's  examination  are:  disloca- 
tion of  the  uterus  and  dislocation  of  both  ovaries,  with  prob- 
ably some  inflammation  in  the  region  of  the  adnexa.  If  her 
pelvic  pain  is  sufficient  to  give  her  grave  concern  and  to  inter- 
fere with  her  duties,  I  think  she  would  be  much  benefited  by  an 
operation ;  but  whether  she  is  operated  upon  or  not  we  ought 
to  do  something  for  her  general  state ;  and  inasmuch  as  I  think 
she  has  an  excess  of  thyroid  gland, — has  hyperthyroidism, — 
what  are  we  going  to  do  for  her?  (Ans.  Give  her  ovarian 
extract?) 

While  her  menstruation  is  irregular  and  her  uterus  is 
enlarged,  the  most  pronounced  characteristic  of  her  menstrua- 
tion is  that  she  goes  three  to  four  weeks  over  her  period,  and 
her  uterus  is  enlarged.  Would  you  give  her  thyroid?  No, 
for  she  has  already  a  hyperthyroidism. 

Ans.    Give  her  mammary  extract. 

Why? 

To  reduce  the  cervix  and  uterus. 

Very  good.  Give  her  ovarian  extract?  Yes;  why  not 
give  her  ovarian  extract?  One  of  the  fundamental  changes 
here  is  the  gradual  diminution  of  the  function  of  the  ovaries. 
Then  why  not  give  ovarian  extract  for  the  constitutional  ef- 
fect, if  not  for  any  other  reason?  The  ovarian  extract  will 
make  her  menstruate  regularly.  If  you  fear  it  will  make  her 
menstruate  too  much,  you  have  already  decided  to  give  her 
mammary;  so  if  you  give  mammary  extract  plus  ovarian  ex- 
tract you  will  overcome  any  tendency  that  may  result  in  the 
direction  of  too  much  bleeding.     Is  that  right? 

Would  you  give  her  suprarenal  extract?  Yes;  unless 
her  blood  pressure  is  very  high,  and  on  general  principles,  even 
then,  there  is  no  very  great  objection  to  giving  a  little  supra- 
renal extract, — not  adrenalin. 


CLINICS  Z7Z 

Would  you  give  her  pituitary  extract?  No  one  of  you 
seems  to  know  of  any  reason  for  giving  it.  I  don't  know  of 
any  particular  reason  why  she  should  get  it.  \\^e  are  not 
desirous  of  stimulating  bony  growth  by  the  anterior  lobe  of 
the  pituitary:  the  posterior  would  stimulate  menstruation,  but 
she  has  too  much  posterior  pituitary  now.  If  we  gave  either, 
it  would  be  the  anterior.  \\'ith  the  combination. — ovarian, 
mammary,  and  possibly  some  suprarenal,  we  will  write. 

5  grains  of  ovarian  extract 

5  grains  of  mammary  extract 

1  or  2  grains  of  supra-renal 
in  a  capsule  and  give  that  three  times  a  day. 

In  addition  to  that,  if  the  patient  is  highly  nervous,  hy- 
persensitive, or  sleepless,  bromides  would  do  a  great  deal  of 
good.  There  are  some  patients  who  suffer  from  intractable 
headaches.  The  source  of  some  headaches  is  referred  to  the 
pituitary  gland,  that  is  a  dyspituitarism, — in  many  cases  an 
enlarged  gland  which  stretches  its  covering  to  such  an  extent 
that  the  headache  is  severe  and  intractable.  Yet  we  are  ad- 
vised to  give  pituitary  extract  for  these  cases,  and  in  many 
instances  they  are  said  to  improve  on  pituitary  extract, — 
whole  gland, — 2  or  3  times  a  day, — so  that  the  administration 
of  pituitary  gland  in  any  patient,  granting  that  we  find  such 
an  anomaly,  may  be  held  in  reserve  for  further  consideration. 
The  headaches  due  to  posterior  pituitary  overactivity  are  often 
relieved  by  placental  extract.  The  headaches  are  due  to  in- 
increased  tension  in  the  cerebrospinal  canal.  The  one  thing 
that  this  patient  needs  most,  apparently,  is  the  extract  of  ovary, 
whole  gland,  not  corpus  luteum. 

On  what  do  you  make  the  diagnosis  of  hyperthyroidism? 
She  has  a  very  decided  palpitation  and  a  tremor  of  the  hands. 

How  long  shall  we  give  the  ovarian  extract?  For  some 
months. 

Locally,  she  should  have  hot  douches  of  any  drug  you 
like, — boric  acid,  iodine,  aluminum  acetate,  etc. 

The  point  of  discussing  this  case  so  extensively  is  that 
she  came  to  the  clinic  complaining  of  various  symptoms,  and 


374  THE    ENDOCRINES 

that  the  laceration  of  the  cervix  and  the  retroflection  which 
we  find  are  not  responsible  for  her  general  symptoms  by  re- 
flex.   That  is  the  point. 

One  point  more.  I  wish  to  call  your  attention  to  the 
fact  that  this  patient  has  had  three  miscarriages,  after  she  had 
had  five  children.  I  think  it  would  be  very  unwise  to  con- 
clude that  the  laceration  of  the  cervix  or  the  retroflexion  ver- 
sion was  responsible  for  the  miscarriages.  In  the  examination 
which  the  Doctor  made  with  the  sound  we  found  little  change 
in  the  lining,  and  the  history  does  not  speak  for  endometrium ; 
so  I  think  the  evidence  adduced  by  the  three  miscarriages 
points  directly  to  an  endocrine  aberration.  In  just  these  few 
sentences  I  can  tell  you  that  I  believe  many  very  early  miscar- 
riages may  be  due  to  an  overgrown  endometrium.  The  egg 
settles  in  a  bad  spot.  Many  miscarriages  are  probably  due  to 
poor  localization  of  the  ovum, — that  is  localization  in  the  lower 
area  of  the  uterus  where,  if  the  egg  were  not  aborted,  a  placen- 
ta praevia  might  develop.  A  few  miscarriages  and  abortions 
are  due  to  a  syphilitic  state,  but  the  largest  number  of  habitual 
miscarriages  are  due  to  endocrine  aberration;  excess  of  the 
posterior  pituitary,  so  that  today,  in  speaking  of  repeated 
miscarriages,  the  Wassermann  reaction  plays  nothing  like  so 
important  a  role  as  it  did  a  few  years  ago. 

Case  II.  This  patient  is  29  years  of  age;  she  has  been 
married  eight  years,  and  comes  to  us  complaining  of  pain  in 
both  hypochondriac  regions,  down  the  back,  and  in  the  pelvis. 
One  year  ago  she  had  a  curettage  after  a  miscarriage.  She 
has  two  children,  apparently  normal, — seven  and  five  years 
of  age.  There  is  very  little  in  the  history.  Her  menstruation 
lasts  a  few  days. 

Has  she  pain  after  eating?  Yes.  Has  she  any  pain  in 
her  legs?    Yes. 

Do  you  know  of  the  surest  way  to  find  out  whether  a 
patient  whom  you  suspect  of  having  hyperthyroidism  has  hy- 
perthyroidism ?  Supposing  you  have  a  patient  and  you  think 
she  is  suffering  from  hyperthyroidism;  how  can  you  prove 
to  yourself  that  it  is  so  ?    Ans.   Give  her  thyroid  extract. 


CLINICS  375 

Of  course.  The  administration  of  thyroid  is  one  of  the 
most  valuable  therapeutic  diagnostic  procedures  that  we  have. 
If  a  patient  complains  of  tachycardia,  and  you  want  to  know 
if  she  has  hyperthyroidism,  give  her  thyroid  for  two  or  three 
weeks.  If  she  has  hyperthyroidism,  it  will  get  worse,  of 
course.  Don't  imagine  every  hyperthyroidism  means  exoph- 
thalmos or  goitre, — or  persistent  tachycardia  or  persistent 
tremor.  It  delights  me  when  I  now  read  in  various  journals 
about  hyperthyroidism,  and  they  say  the  gland  is  not  enlarged. 
The  gland  is  not  enlarged  in  thousands  of  cases  where  there  is 
hyperthyroidism.  The  gland  may  oversecrete  even  when  it  is 
not  enlarged,  and  it  may  undersecrete  and  not  be  diminished  in 
size ;  and  it  can  be  diminished  in  size  and  still  not  undersecrete. 
In  operating  you  remove  a  part  of  the  gland  and  the  rest  still 
does  its  work,  and  it  can  overwork  when  it  is  not  enlarged. 
So  in  many  a  case  you  have  to  make  your  diagnosis  by  other 
signs  than  enlargement  of  the  gland. 

The  same  plan  of  diagnosis  may  be  followed  in  a  patient 
who  is  two  or  three  weeks  over  time  and  you  don't  know 
whether  or  not  she  is  pregnant.  If  you  give  her  ovary  and 
thyroid  and  she  does  not  menstruate,  you  generally  prove  by 
this  therapeutic  procedure  that  she  is  pregnant ;  otherwise  the 
combination  of  ovarian  and  thyroid  would  make  the  patient 
menstruate  again ;  and  it  is  not  a  bad  combination  to  give,  for  it 
does  not  produce  a  miscarriage  as  do  many  things  that  are 
given  for  diagnostic  reasons. 

We  find  in  this  patient  a  small  cervix,  a  uterus  in  fairly 
normal  position;  adnexa  fairly  normal, — possibly  the  ovary  is 
a  little  enlarged. 

A  Doctor.     I  don't  find  very  much  trouble. 

Well,  you  are  warm.    What  shall  we  do  with  her  ? 

Ans.   Send  her  to  another  department. 

Dr.  Bandler.  That  is  right.  I  purposely  have  not  said 
anything  that  might  influence  you  in  your  diagnosis.  Why? 
If  she  has  gallstones,  it  is  not  due  to  this  pelvic  condition.  If 
she  has  a  distended  stomach  or  an  ulcer,  it  is  not  due  to  the 


376  THE    ENDOCRINES 

pelvic  condition.  In  other  words,  sh*?  is  not  a  gynaecological 
case.     Is  that  so? 

Ans.     I  don't  find  anything. 

No.  There  is  not  anything  down  below  to  be  made  re- 
sponsible for  the  symptoms  of  which  she  complains.  There- 
fore, as  this  is  a  gynaecological  clinic,  we  will  send  her  back 
to  the  department  that  referred  her  here. 

Post-Graduate  Hospital 

December  5,  1919 

Case  I.  This  patient  is  24  years  old,  and  comes  com- 
plaining chiefly  of  backache,  and  leucorrhoeal  discharge;  pain 
in  the  lower  abdomen  for  years,  which  is  worse  after  menses. 
She  has  had  no  children,  but  has  had  two  miscarriages,  one 
two  years  ago,  the  other  sixteen  months  ago.  She  had  a  curet- 
tage following  the  first  miscarriage.  Her  menstrual  history 
began  at  18;  menses  moderate,  with  blood  clots,  but  no  pain. 

The  complaint  is  chiefly  of  pain  in  the  lower  abdomen. 
The  patient  has  had  no  children,  but  had  two  miscarriages — 
the  first  time  at  two  months  and  was  curetted;  then  became 
pregnant  again  and  carried  for  six  months.  Although  she  mis- 
carried twice,  this  comes  under  the  head  of  what  might  be 
termed  one-child  sterility.  Such  a  patient  has  a  baby  and  does 
not  become  pregnant  a  second  time;  or  has  a  miscarriage  and 
does  not  conceive  again.  From  the  history,  it  seems  that  some- 
thing took  place  with  the  second  miscarriage  which  has  pre- 
vented subsequent  conception.  She  menstruates  every  four 
weeks  for  three  days.  (Was  ten  days  in  the  hospital  after 
the  second  miscarriage.) 

When  a  patient  conceives  once  and  finds  difficulty  in  con- 
ceiving a  second  time,  you  may  presume  that  something  has 
taken  place  either  in  the  normal  physiological  processes  or  that 
a  new  and  acquired  condition  has  come  on.  That  acquired 
condition  is  frequently  a  mild  inflammation.  You  can  under- 
stand that  after  a  labor,  with  forceps,  or  lack  of  proper  care, 
etc.,  a  mild  inflammation  may  involve  the  tubes  and  ovaries. 
That  same  involvement  may  occur  after  a  miscarriage,  with 


CLINICS  377 

or  without  a  curettage.  If  we  can  remove  from  the  field  of 
probabiHty  an  infection  or  inflammation,  then  we  are  deahng 
simply  with  some  physiological  change,  the  most  frequent  of 
which  is  one  which  involve  the  tubes  and  ovaries. 

Here  is  a  patient  with  a  uterus  in  anteflexion  but 
retrodisplaced.  You  can  gather  the  distinction  between  the 
two.  She  holds  the  rectus  very  rigid  as  I  examine  bimanually. 
and  I  can  feel  the  ovary  of  that  side  very  enlarged  and  cystic. 
The  right  adnexa  are  apparently  normal  to  the  touch,  and  the 
patient  shows  no  pain.  So,  to  repeat,  she  has  a  retrodisplace- 
ment  of  the  uterus,  the  uterus,  however,  being  very  mov- 
able; she  is  sensitive  and  very  rigid  on  the  left  side,  and  we 
feel  a  prolapsed  movable  ovary  which  is  distinctly  cystic  to 
the  touch. 

A  retroversion  or  a  retroflexion  constitute  what  is  ac- 
curately described  as  a  retrodeviation,  that  is  a  backward 
deviation  of  the  fundus  from  the  normal  anteflexed  position; 
whereas  retrodisplacement  means  that  the  entire  uterus, — 
cervix,  fundus,  etc., — is  displaced  backward  toward  the  hol- 
low of  the  sacrum.  Hence  you  may  have  a  retrodisplaced 
uterus  with  the  fundus  anteflexed,  or  you  may  have  a  retro- 
displacement  with  a  retroverted  fundus  uteri. 

If  this  represents  the  sacrum  and  this  the  symphysis,  and 
this  the  normal  position  of  the  uterus, — if  the  fundus  of  the 
uterus  deviates  backward  you  have  a  retroversion;  if  it  devi- 
ates still  further  you  may  have  a  retroflexion, — that  is  a  devia- 
tion or  change  of  position  on  the  part  of  the  fundus ;  it  may 
be,  as  a  result,  for  instance,  of  a  lengthening  of  the  round 
ligaments;  but  if  the  whole  uterus  is  pushed  back  you  have  a 
retrodisplacement. 

In  a  backward  displacement  of  the  whole  uterus,  usually 
the  fundus  falls  back,  but  it  may  still  be  forward  in  a  position 
called  anteflexion.  So  retrodisplacement  is  a  change  of  posi- 
tion of  the  whole  uterus,  with  the  cervix  as  the  most  important 
point  displaced ;  for  after  all,  it  is  the  position  of  the  cervix 
which  determines,  in  most  cases,  the  position  of  the  fundus. 
If  the  cervix  is  high  up  and  far  back,  the  fundus  will  naturally 


378  THE    ENDOCRINES 

fall  forward ;  if  the  cervix  is  displaced  downward  and  forward, 
the  fundus  will  naturally  fall  backward.     Do  you  see  that? 

This  fundus  is  extremely  movable;  on  the  right  side  I 
don't  feel  anything;  on  the  left  side  is  a  prolapsed  ovary.  Now 
we  will  introduce  a  speculum  and  examine  the  cervix.  The 
purpose  of  this  vaginal  examination  is  to  look  at  the  cervix 
for  evidences  of  a  possible  infection  or  inflammation.  You 
see  a  slight  eversion  of  the  lips  of  the  cervix,  which  in  parous 
women  is  natural,  the  patient  having  been  delivered  of  a  foetus 
six  months  old.  You  see  no  redness,  no  discharge  of  a  puru- 
lent nature,  and  no  mucus  from  the  cervix.  So  far  as  this 
relatively  superficial  examination  is  concerned  we  see  nothing 
in  the  cervix  that  is  definite  proof  of  the  existence  of  an  in- 
flammation. However,  that  is  no  proof  that  there  is  no  inflam- 
mation, for  only  the  other  day  we  showed  a  patient  suffering, 
subsequent  to  marriage,  from  pain  in  the  pelvis,  leucorrhoea 
and  menorrhagia;  and  I  stated  then  that  when  a  patient  sub- 
sequent to  marriage  acquires  a  pain  different  from  what  she 
has  had  before,  or  acquires  a  leucorrhoeal  discharge  which  is 
not  a  hypersecretion,  and  acquires  a  menorrhagia, — those  three 
points  taken  together  suggest  an  inflammation ;  and  in  that  pa- 
tient some  weeks  ago  the  diplococci  of  Neisser  were  found, 
and  yet  outside  of  the  erosion  of  the  cervix  there  was  no  other 
external  evidence  of  any  inflammation;  but  I  did  find  then 
sensitive  ovaries  that  were  cystic. 

This  patient's  left  ovary  is  sensitive  and  movable,  yet 
there  may  be  some  adhesions.  It  is  a  frequent  experience  to 
operate  and  find  tubes  with  the  ends  closed  and  yet  not  en- 
larged. In  other  words,  we  are  accustomed  to  think  of  a  sal- 
pingitis as  an  enlarged  tube  with  a  retained  secretion.  It  does 
not  have  to  be  that  way.  There  may  have  been  a  mild  inflam- 
mation and  the  outer  ends  of  the  fimbriated  extremity  are 
closed,  but  no  further  inflammation  takes  place  and  the  tubes 
are  not  palpable, — hardly  larger  than  normal.  If  the  outer  ends 
are  closed,  they  may  likewise  be  bound  down  by  cobweb  ad- 
hesions which  are  enough  to  be  responsible  for  either  pain  or 
sterility. 


CLINICS  379 

This  patient  has  pain  and  backache.  We  may  consider 
the  backache  as  due  possibly  in  some  degree  to  this  retrodis- 
placement.  Most  of  these  cases  are  due  to  a  chronic  cervical 
catarrh,  eventually  ending  in  retraction  of  the  utero-sacral  liga- 
ments. We  find,  with  the  eye  and  our  fingers,  evidences  of 
inflammation.  The  condition  suggests,  with  a  chronic  cervical 
irritation,  a  possibility  of  the  tubes  being  closed  without  our 
feeling  it;  or  possibly  cobweb  adhesions  which  cannot  be  felt. 

Granting,  however,  that  this  patient  has  no  cobweb  ad- 
hesions, or  that  she  has  no  closed  tubes,  why  is  it  that  having 
conceived  twice  she  is  sterile  now?  You  must  realize  that 
every  miscarriage  and  every  premature  labor  renders  the  pos- 
sibility of  a  subsequent  pregnancy  less  probable.  It  does  not 
by  any  means  make  it  impossible,  for  you  know  dozens  of 
cases  of  patients  who  have  miscarried  two  to  six  times  and  still 
continue  to  become  pregnant;  but,  on  the  other  hand,  many 
cases  miscarry  only  once  and  never  again  conceive.  Can  you 
explain  that  by  any  condition  other  than  inflammation? 

Yes,  the  only  explanation  you  can  give  is  that  such  cases 
do  not  ovulate,  and  by  that  we  do  not  mean  that  there  is  no  de- 
velopment of  the  ovum  in  the  Graafian  follicle.  AVe  mean 
that  the  expulsion  of  the  ovum  does  not  take  place  because  the 
ripe  follicle  does  not  break.  As  a  result,  in  many  of  these 
cases,  there  occur  cystic  changes  in  one  or  both  ovaries  which 
result  in  the  failure  of  subsequent  Graafian  follicles  to  ripen 
and  throw  out  their  ovum.  Therefore,  when  you  are  in 
doubt, — and  in  one-child  sterility  it  is  not  necessary,  as  a  rule, 
to  examine  spermatozoa, — your  therapy  is  directed  mainly  to 
promoting  ovulation. 

This  patient  should  be  given  douches  as  a  general  prop- 
osition, and  the  best  is  either  boracic  acid  or  aluminum  acetate ; 
and  in  addition  you  will  give  her  a  prescription  of  some  of 
the  endocrines,  with  the  idea  of  promoting  the  bursting  of  the 
follicles.  I  am  sure  I  do  not  need  to  give  you  any  information 
in  regard  to  that  for  you  all  know  about  it.  We  will  give  this 
patient  both  ovarian  secretion, — the  whole  gland, — and  thy- 
roid, in  capsule  form,  three  times  a  day, — grain  v-x  of  the 


380  THE    ENDO CRIMES 

whole  ovary  and  1/10  or  1/6  of  the  thyroid  gland.     In  that 
combination  we  have  the  best  agency  for  stimulating  ovulation. 

Case  II.  This  patient  is  48  years  old ;  she  has  been  mar- 
ried twenty-five  years  and  has  had  five  children,  the  youngest 
ten  years  old.  She  has  nursed  all  her  babies.  She  has  had  two 
miscarriages,  the  last  11  years  ago.  Her  menstrual  history 
began  at  15,  moderate  and  regular.  She  had  her  last  period  a 
year  ago.  She  complains  chiefly  of  pain  in  the  abdomen,  burn- 
ing on  urination,  and  a  leucorrhoeal  discharge,  yellowish  white 
in  character;  also  frequency  of  urination, — every  hour, — ac- 
companied by  pain.  She  has  had  flushes,  but  not  now.  She 
has  lost  in  weight. 

Here  is  a  woman  forty-eight  years  of  age  with  amenor- 
rhoea  of  a  year  (her  last  menstruation  was  a  year  ago),  who 
has  suffered  since  then  with  relatively  few  if  any  flushes  or 
flashes,  and  very  few  of  the  various  phenomena  associated  with 
the  climacteric  period.  Many  women  go  through  this  change 
of  life  period  as  they  go  through  their  adolescent  develop- 
mental period,  without  any  phenomena  at  all.  Sometimes- 
the  menstruation  grows  gradually  less  from  month  to  month 
and  runs  a  diminishing  course  until  it  disappears;  in  other 
cases  there  will  be  a  period  of  amenorrhoea  for  two  or  three 
months,  and  then  the  menstruation  may  be  restored  for  a  long 
time.  In  many  cases  it  ceases  at  once  and  never  recurs ;  but  as 
a  rule  there  is  an  interchange  between  amenorrhoea  and  men- 
struation for  varjnng  periods.  Women  are  supposed  to  expect 
menorrhagia  and  metrorrhagia  as  the  usual  course.  That  is 
not  correct.  Any  patient  who  suffers  from  regular  excessive 
or  irregular  and  excessive  menstruation  has  something  ab- 
normal accompanying  the  change.  This  notion  on  the  part 
of  the  laity  and  among  many  doctors  prevents-  many  patients 
from  seeking  advice  early  enough  to  prevent  increase  in  size  of 
fibroids  or  to  recognize  early  carcinoma.  Diminishing  men- 
struation is  the  typical  accompaniment  of  the  menopause,  not 
excessive  menstruation. 

In  addition  to  constitutional  symptoms,  in  some  patients 
the  flushes  and  flashes  are  terrific ;  many  suffer  from  excessive 


CLINICS  381 

nervous  upsets, — sometimes  of  the  excitable  type,  sometimes 
of  the  depressed  type.  During  this  change  of  life  period  psy- 
choses are  prone  to  develop.  It  would  be  wrong,  however, 
to  say  that  the  change  of  life  period  produces  psychoses ;  and 
it  would  be  wrong  to  say  that  cessation  of  menstruation  causes 
them.  It  simply  means  that  at  this  climacteric  period,  when  the 
endocrines  are  rearranging  themselves  on  a  new  basis,  patients 
may  suffer  from  a  temporary  hypo  or  hyperthyroidism,  or  a 
temporary  hypo  or  hyperpituitarism,  or  a  hypo  or  hyperadre- 
nalism.  During  this  period  of  readjustment  a  latent  tendency 
to  a  psychosis  may  develop  further,  since  it  is  brought  out  by 
these  varying  adjustments  of  the  glands.  Of  them  all,  you  will 
probably  find  the  depressed  stages,  simulating  the  myxoede- 
matous  type,  the  more  frequent.  Again,  you  will  find  the  type 
where  patients  will  alternate  between  the  depressed  and  the 
excitable,  which  in  many  instances  means  a  hyper  or  hypo- 
thyroidism, a  hyper  or  hypopituitarism,  a  hypo  or  hyperadre- 
nalism,  etc. ;  and  in  this  stage  there  is  a  tendency  to  glycosuria 
and  a  great  tendency  to  high  blood  pressure.  All  of  that, 
theoretically  and  by  the  test  of  therapy,  can  be  referred  to 
changes  in  the  various  endocrines,  especially  the  posterior 
pituitary. 

Now,  then,  what  evidence  have  we  as  to  what  local 
changes  are  occurring  in  this  menopause.  The  first  is  the 
trophic  change,  which  means  a  diminution  in  the  size  of  the 
uterus,  an  atrophy  of  the  uterus.  That  is  the  first.  The  next 
is  the  diminution  in  the  trophic  care  of  the  external  genitalia, 
the  vagina,  etc.,  of  women  at  the  change  of  life  period,  or  after 
the  change  of  life  period.  They  are  very  susceptible  to  vag- 
initis, the  most  typical  of  which  is  called  senile  vaginitis.  They 
are  very  susceptible  to  pruritus  vulvae.  Occasionally  this  is  on 
a  diabetic  basis,  but  aside  from  this  the  vulva  is  frequentlv  the 
site  of  pruritus  and  irritation.  Then  comes  the  most  extreme 
type  of  external  change,  of  atrophy, — the  blanching  of  the 
mucous  membrane  and  the  skin,  a  drying  up  and  drawing  to- 
gether or  sclerosis,  so  that  the  entrance  to  the  vagina  is  nar- 
rowed so  that  one  finger  can  scarcely  enter.   This  is  known  as 


382  THE    ENDOCRINES 

kraurosis  vulvae.  All  of  these  changes  are  due  to  lack  of  proper 
care  and  control  by  the  internal  secretions  that  preside  over  the 
nutrition  of  the  entire  genital  tract;  and  the  disappearance  of 
that  control  makes  the  external  genitalia  susceptible  to  infec- 
tions, etc.  This  patient  complained  of  frequency  of  urination. 
Burning  on  urination  is  not  truly  a  part  of  a  diabetic  condition. 
The  first  thing  in  these  cases  is  to  exclude  diabetes,  which  is 
easy.  You  will  have  in  many  diabetic  patients  an  appearance 
of  the  vulva  that  is  almost  typical  and  characteristic.  If  I  were 
looking  at  the  vulva  of  this  patient,  without  any  notion  of  her 
history,  the  first  thing  I  would  suggest  would  be  to  see  and  to 
examine  the  urine,  for  while  the  vulva  is  by  no  means  typical 
it  is  suggestive  of  diabetic  vulvitis, — the  skin  and  vulva  being 
a  shiny  darkish  red  and  leathery  in  appearance. 

Then  you  have  other  cases  of  diabetic  vulvitis  with  irrita- 
tion and  itching  but  without  a  sign  of  change  of  color.  (As- 
sistant tests  urine:  This  patient  is  diabetic.  There  you  have 
it.)  While  that  is  not  as  typical  as  in  some  cases,  it  is, — as  you 
now  know,  a  genuine  diabetic  vulvitis.  She  knows  now  that 
for  five  years  she  has  been  a  diabetic  (she  just  now  volunteers 
the  information).  So  we  have  here  the  explanation  of  her  fre- 
quency of  urination,  and  an  explanation  of  the  external  irrita- 
tion, and  an  explanation  of  the  appearance  of  the  vulva. 

So  we  have  diabetic  patients  that  complain  of  pruritus 
vulvae, — some  that  complain  of  no  such  manifestations, — but 
don't  imagine  that  pruritus  vulvae  is  always  evidence  of  a 
diabetes.  By  no  means.  Just  as  men  may  have  furuncles,  etc., 
on  the  back  of  the  neck,  women  may  have  a  follicular  disturb- 
ance here.  The  best  thing  we  can  do  for  such  non-diabetic 
cases  is  to  innoculate  them  with  vaccines.  That  helps  most 
cases  of  recurrent  furuncles.  Many  persons  are  potential  dia- 
betics for  years.  We  know  that  as  woman  approaches  the 
change  of  life  period  the  alterations  of  the  endocrine  glands 
bring  out  this  tendency  or  develop  it;  and  you  know  that  the 
later  in  life  the  patient  develops  it  the  less  danger  it  is  to  the 
prolongation  of  life.     A  man  or  woman  becoming  diabetic  at 


CLINICS  383 

45  or  50  may  still  live  twenty  or  thirty  years,  but  a  child  ac- 
quiring diabetes  has  an  almost  fatal  condition. 

We  know  very  little  except  in  a  very  general  way  about 
the  various  forms  of  diabetes.  There  are  various  forms  aside 
from  the  pancreatic  and  renal.  We  know  there  are  glycosurias 
that  do  not  constitute  diabetes  which  are  related  to  the  thyroid 
adrenals  or  pituitary,  and  these  interest  us  most,  for  the  thyroid 
and  pituitary  play  an  important  part  in  the  functions  of  the 
female  as  they  concern  the  gynaecologist  and  obstetrician. 
Many  of  my  pregnant  patients  have  a  transient  glycosuria 
which  disappears,  and  I  have  considered  most  of  them  as  pitui- 
tary in  nature. 

I  have  a  patient  upstairs  who  was  pregnant  nearly  seven 
months.  Her  physician  examined  her  and  found  that  she  com- 
plained of  persistent  headaches  and  defective  vision  and  he 
found  a  blood  pressure  of  190.  He  examined  her  urine  and 
found  albumin,  and  sent  her  to  me.  I  tried  to  carry  her  along 
for  two  weeks  or  a  month,  and  gave  her  Murphy  drip,  etc.  Her 
blood  pressure  remained  at  190,  the  hyaline  and  granular  casts 
increased,  her  vision  began  to  grow  progressively  bad.  Where- 
as in  the  morning  she  could  see  the  flowers  on  her  stand,  she 
could  only  see  a  haze  in  the  afternoon,  and  in  the  evening  she 
developed  an  eclamptic  attack.  She  was  treated  with  1/6 
or  1/4  grain  of  morphine  every  two  hours.  Another  thing 
we  did  was  to  give  high  colonic  irrigations.  The  next  morning 
she  went  into  labor,  after  a  dose  of  castor  oil,  and  was  delivered 
of  a  dead  fetus.  Since  her  eclampsia  she  has  developed  an 
occasional  glycosuria,  not  present  before,  but  present  since. 
Whether  that  is  due  to  some  change  in  the  pancreas  or  the 
liver,  we  don't  know,  but  since  we  consider  pituitary  plus  and 
thyroid  minus  as  all  important  factors  in  eclampsia  it  may  be 
just  as  well  to  look  to  those  endocrines  in  all  our  obstetric 
cases. 

What  shall  we  do  for  this  patient?  The  treatment  of 
these  cases  of  vulvitis  is  firstly  general, — as  to  diet;  second, 
general  as  to  medication,  in  which  codein  plays  an  important 


384  THE    ENDOCRINES 

part.  But  locally  the  patient  complains  of  frequency  of  urina- 
tion and  of  itching.  For  that  we  must  give  relief.  If  this 
patient  takes  a  douche  every  day,  aluminum  acetate,  a  teaspoon- 
ful  in  2  quarts,  and  if  she  applies  externally  to  the  vulva  an 
ointment  composed  of  dermatol  zi  to  each  ounce  of  zinc  oint- 
ment, and  keeps  it  on  almost  constantly, — not  washing  it  off, 
but  removing  it  occasionally  with  olive  oil, — that  will  prob- 
ably give  her  as  much  relief  as  any  combination  that  I  know 
of.  Dust  the  ointment  very  liberally  with  talcum  powder  so 
that  it  forms  a  thick  paste,  and  let  that  stay  on  all  the  time, — 
occasionally  being  washed  off  with  olive  oil  and  replaced.  That 
with  the  proper  diet  constitutes  the  treatment. 

It  has  been  said  that  the  sugar  from  the  urine,  coating 
the  whole  external  genital  region,  forms  the  ground  on  which 
fungi,  etc.,  grow  and  flourish,  producing  the  dermatitis;  and 
some  persons  have  treated  that  condition  by  washing  thorough- 
ly with  soap  and  water,  and  then  with  alcohol,  and  then  bath- 
ing the  parts  with  bichloride  of  mercury, — 1/5,000,  and  so 
destroying  the  fungi  or  other  growths  responsible  for  the  con- 
dition. 

It  is  interesting  when  we  study  the  cass  of  pruritus  that 
we  see  to  observe  other  neighboring  annnoyances  and  irrita- 
tions, especially  such  as  are  seated  around  the  anus.  You  see 
then,  sometimes  in  bad  cases,  that  the  area  around  the  anus  is 
furrowed  like  the  spokes  of  a  wheel,  etc.,  and  many  of  these 
cases  are  found  to  be  due  to  bacteria,-^hence  many  cases  are 
cured  by  autovaccines  or  by  mixed  stock  vaccines ;  so  that  we 
cannot  deny  the  possibility  of  the  association  of  some  form  of 
bacteria  on  the  surface.  The  ideal  thing  would  be  to  have  a 
test  made  to  see  whether  any  bacteria  are  present. 

The  urine  is  clear,  so  we  have  no  associated  cystitis.  Stock 
vaccines,  streptococcus  and  staphylococcus  mixed,  would  prob- 
ably help  this  patient. 

Placental  extract  is  worthy  of  trial  in  glycosuria  due  to 
posterior  pituitary  overactivity. 


CLINICS  385 

Lecture  at  Post-Graduate  Hospital 
November  18,  1919 

I  am  going  to  speak  to  you  this  morning  on  the  subject  of 
the  endocrine  glands,  and  will  devote  as  much  of  the  time 
as  possible  to  the  pituitary  body.  The  first  phase  of  pituitary 
activity  that  attracted  the  attention  of  gynaecologists  and  ob- 
stetricians was  the  fact  that  pituitrin,  which  is  made  from  the 
posterior  lobe,  has  a  very  powerful  effect  in  labor  in  that  it 
stimulates  the  uterus  to  a  very  great  and  powerful  and  rhythmic 
action.  If  you  give  pituitrin  to  a  patient  you  will  always  get 
some  contraction  of  the  uterus.  For  example,  before  a  Cae- 
sarian section  we  give  a  hypodermic  of  pituitrin  so  that  the 
uterus  is  well  contracted  before  we  make  the  incision,  but  it 
does  not  produce  the  rhythmical  contractions  the  uterus  in 
labor  demands.  If,  however,  the  patient  shows  by  the  pre- 
liminary symptoms  that  she  is  going  into  labor,  then  pituitrin 
will  bring  about  the  regular  rhythmical  action. 

On  the  other  hand,  the  pituitrin,  so  far  as  its  specific 
action  in  trying  to  expel  the  baby  is  concerned,  seems  to  act 
only  when  the  patient  is  ready  and  sensitiveness  is  established 
in  the  patient.  What  establishes  that  sensitiveness  we  do  not 
know,  but  pituitrin  will  act  in  specific  fashion  on  the  280th  day 
or  thereabout  and  will  not  at  any  other  period.  When  a  patient 
is  miscarrying  or  you  are  curetting  a  patient  going  through 
a'  miscarriage,  pituitrin  will  have  some  effect  in  contracting  the 
uterus,  so  that  something  new  in  the  element  of  pregnancy  has 
sensitized  the  uterus  to  the  action  of  pituitrin.  That  gives  evi- 
dence that  the  pituitary  body, — ^the  posterior  lobe  we  are  speak- 
ing of, — has  an  intimate  and  direct  connection  with  the  genital 
tract. 

There  is  a  condition  which  is  known  as  dystrophia  adiposo- 
genitalis, — a  condition  which  is  probably  due  to  an  involve- 
ment of  the  posterior  lobe  more  than  any  other  part  of  the 
gland,  whereby  a  diminution  of  the  secretion  of  the  posterior 
lobe  extending  over  a  long  period  is  evidenced  by  two  factors : 
First,  interference  with  the  carbohydrate  metabolism  so  that 

25 


386  THE    ENDOCRINES 

the  patient  increases  progressively  in  weight  and  becomes  fat. 
Associated  with  this  condition  is  a  progressive  diminution  in 
the  loss  of  blood  at  menstruation,  and  that  is  followed  by  a 
diminution  in  the  size  of  the  uterus.  That  affects  many  women 
between  the  ages  of  22  to  30.  They  grow  progressively  stouter 
and  stouter,  and  an  examination  will  show  that  the  uterus  has 
undergone  a  certain  degree  of  atrophy.  That  is  mainly  due  to 
a  deficient  secretion  of  the  posterior  lobe ;  how  far  the  anterior 
lobe  is  involved  has  not  been  decided.  If  you  have  that  picture 
before  you  as  an  evidence  of  the  lack  of  activity  of  the  posterior 
lobe,  what  picture  would  you  have  to  show  hyperactivity  of 
the  posterior  lobe  ? 

If  you  have  a  hyperactivity  of  the  posterior  lobe  and  there 
is  no  interference  with  carbohydrate  metabolism  the  patient 
may  not  be  stout.  If  you  have  an  active,  normal,  or  hyper- 
active lobe,  menstruation  ought  not  to  diminish,  the  uterus 
ought  not  to  atrophy, — so  that  you  ought  to  have  a  patient 
not  stout,  a  uterus  not  small,  and  a  menstruation  not  diminish- 
ing. Therefore,  if  an  overactivity  of  the  posterior  lobe  exerts 
an  overstimulation  in  a  trophic  way  on  the  genitalia,  what 
would  you  expect  a  uterus  of  that  sort  to  be?  Enlarged, 
myomatous  in  character,  or  a  uterus  which  has  within  its  walls 
a  fibroma  or  a  myoma;  so  the  probability  is  that  cases  of 
fibromata  and  myomata,  and  many  cases  of  enlarged  uterus  are 
due  to  an  overactivity  of  the  posterior  lobe  of  the  pituitary 
gland.    That  follows  logically. 

If  that  be  the  case,  the  hyperactivity  of  the  posterior  lobe 
should  be  evidenced,  among  other  things,  by  a  tendency  to  an 
increase  of  sugar  in  the  urine  or  in  the  blood  under  a  normal 
diet  or  increased  carbohydrate  diet,  or  after  a  test  made  with 
lactose  or  glucose  or  other  sugar-producing  substances. 

One  function  of  all  glands  is  to  resist  an  inroad  made  upon 
the  system  by  an  infection  or  by  a  strain,  or  by  a  new  process 
going  on.  When  a  patient  becomes  pregnant  there  settles  in 
the  uterus  a  fecundated  ovum.  The  first  evidence  of  that 
fecundated  ovum  is  a  cessation  of  menstruation.    That  shows 


CLINICS  387 

that  certain  gland  actions  that  normally  produce  menstruation 
are  inhibited  at  once  by  the  fecundated  ovum.     What  does  it  ? 

The  outer  layer,  the  shell  of  this  growing  egg,  is  composed 
of  what  are  known  as  trophoblast  cells,  and  they  develop  subse- 
quently into  the  placenta,  and  it  is  they,  and  their  secretion 
which  is  thrown  into  the  blood,  which  nullify  or  antagonize 
those  gland  elements  which  normally  produce  menstruation. 
As  the  fecundated  ovum  grows  larger  and  larger,  and  the 
foetus  develops,  certain  changes  occur  which  are  evident  to 
every  one.  The  thyroid  gland  practically  always  increases 
in  size  and  probably  in  activity,  because  the  body  is  doing  two 
things :  First,  it  is  nourishing  the  growing  embryo ;  and  sec- 
ond it  is  defending  itself  against  an  invasion  by  placental  ele- 
ments. The  suprarenal  gland  undergoes  changes  in  pregnancy, 
and  these  changes  are  stimulated  and  can  be  stimulated  only 
by  something  which  the  placenta  produces.  The  anterior  lobe 
of  the  pituitary  body  undergoes  hypertrophy,  the  cells  increase 
in  size  and  show  all  the  evidences  of  increased  activity  in  preg- 
nancy ;  and  that  lobe  never  returns  to  its  previous  state ;  some 
evidence  of  its  previous  hyperactivity  always  remains  after  a 
patient  has  gone  through  her  first  term.  The  corpus  luteum, 
and  especially  the  true  corpus  luteum,  is  supposed  to  stimulate 
the  thyroid  and  to  somewhat  inhibit  the  pituitary  posterior. 
The  placental  secretion  inhibits  the  true  pituitrin  contractile 
action  of  the  posterior  lobe  until  full  term  is  reached.  It  does 
this  as  a  general  rule.  The  trophic  effect  of  the  posterior  pitui- 
tary during  pregnancy  is  evidenced  among  other  things  by  the 
painless  contractions  of  Braxton-Hicks. 

You  have  the  suprarenal,  the  thyroid,  and  the  anterior  lobe 
showing  an  increased  activity:  first,  to  aid  in  the  nutrition  of 
the  foetus ;  second,  to  protect  the  body  against  the  invasion  of 
these  new  placental  elements.  The  same  thing  holds  true, 
probably,  of  all  the  glands  in  the  body. 

What  does  the  pituitary  lobe  do  during  pregnancy?  It 
produces  in  the  uterus  painless  rhythmical  contractions,  in  na 
wise  severe  or  continuous,  and  without  the  power  of  dilating 
the  cer\-ix,  which  it  does  at  full  term.     It  produces  a  certain 


388  THE    ENDOCRINES 

automassage  of  the  uterus,  so  that  the  latter  grows  larger 
and  is  adapted  to  the  growing  ovum.  The  uterus  at  the  same 
time  grows  larger  of  its  own  accord  and  hypertrophies  through 
glandular  and  pituitary  stimulation.  If  a  normal  uterus  were 
similarly  stretched  for  nine  months  by  the  growing  ovum,  it 
would  be  as  thin  as  paper  at  full  term,  but  as  it  grows,  it  is 
stimulated  to  hyperplasia;  this  automassage  aids  in  that  pro- 
cess, with  the  result  that  you  have  a  greatly  enlarger  uterus, 
and  also  a  hugely  increased  amount  of  muscle, — so  that  you 
have  evidence  of  activity  on  the  part  of  the  anterior  and  pos- 
terior lobes  acting  in  a  trophic  manner  and  since  these  phases 
of  activity  are  produced  by  pregnancy,  and  since  the  placental 
element  in  the  early  months  is  the  only  additional  element  at 
that  time,  we  give  to  the  placental  secretion  part  of  the  credit 
for  these  changes. 

Does  the  placental  extract  do  anything  to  the  ovary?  It 
produces  the  true  corpus  luteum  or  the  true  yellow  body  so 
that  you  have  in  the  ovary  again  an  evidence  that  a  change 
has  taken  place  in  the  character  of  its  secretion  by  what  the 
placental  element  has  thrown  into  the  blood. 

If  the  posterior  lobe  of  the  pituitary  is  responsible  for 
these  changes  (many  of  them)  in  a  woman,  and  if  labor  pains 
are  due  to  the  posterior  lobe  extract, — we  find  no  parallel  of 
the  same  type  in  men, — therefore,  whatever  else  you  can  say, 
you  may  say  this :  The  posterior  lobe  of  the  pituitary  is  emi- 
nently a  feminine  sex  gland. 

Is  the  thyroid  a  female  sex  gland?  Much  more  so  than 
it  is  a  male  gland.  The  thyroid  swells  at  menstruation;  it  in- 
creases in  activity  during  pregnancy,  and  thyroid  diseases  are 
eight  to  ten  times  more  frequent  in  the  female  than  in  the  male. 
Therefore,  the  thyroid  in  its  relations  to  the  other  glands  of 
the  female  sex  is  extremely  sensitive  to  changes.  If  goitre  is 
eight  to  ten  times  more  frequent  in  women  than  in  men,  the 
thyroid  must  be  more  sensitive ;  therefore  its  relation  to  the  sex 
glands  makes  it  probable  that  the  act  of  menstruation  and  the 
presence  of  ovaries  and  the  action  of  the  corpus  luteum  are 
among  the  factors  which  make  the  thyroid  sensitive. 


CLINICS  389 

If  a  patient  menstruates  every  twenty-eight  days  and  at 
the  menstruation  period  has  an  excessive  amount  of  uterine 
contractions  or  a  dilatation  of  the  cervix,  and  if  at  that  time 
uterine  pain  in  the  form  of  dysmenorrhoea  comes  on,  you  may 
safely  say  that  in  that  patient  the  posterior  lobe  of  the  pituitary 
is  acting  in  an  excessive  manner,  simulating  to  a  slight  degree 
its  action  at  full  term.  So  that  whereas  menstruation  is  a  minia- 
ture labor,  it  is  much  more  a  miniature  labor  when  there  is 
dysmenorrhoea.  Therefore,  a  dysmenorrhoea  is  in  all  prob- 
ability due  to  the  fact  that  at  the  menstrual  period  the  posterior 
lobe  is  rendered  sensitive,  throws  its  increased  activity  to  the 
uterus,  and  produces  pain. 

Take  a  patient  pregnant  three  months.  Suppose  today  to 
be  the  day  she  would  have  menstruated  if  she  were  not  preg- 
nant. The  posterior  pituitary  lobe  every  twenty-eight  days, 
even  during  pregnancy,  becomes  hyperactive;  in  the  vast  ma- 
jority of  cases  you  will  note  no  difference,  but  in  some  cases 
the  posterior  lobe  produces  such  contractions  of  the  uterus  that 
the  uterus  will  go  into  labor  at  three  months  of  pregnancy  in- 
stead of  nine  months,  and  you  will  have  a  miscarriage;  so  that 
in  many  cases  repeated  miscarriages, — inasmuch  as  they  occur 
at  or  about  the  time  when  the  patient  would  have  menstruated, 
— are  another  evidence  of  hyperactivity  of  the  posterior  lobe. 

I  will  go  back  now  for  a  moment  to  the  anterior  lobe 
proposition.  A  boy  and  a  girl  are  of  the  same  age,  and  de- 
velop to  twelve  or  thirteen  years.  There  are  differences  in 
the  shape  of  the  body  of  that  boy  and  that  girl.  In  addition  to 
the  fact  that  the  girl  has  mammary  glands,  there  is  a  totally 
different  shape  of  her  pelvis,  her  bony  growth  is  less  marked 
as  a  rule, — not  so  heavy;  there  is  a  totally  different  distribu- 
tion of  the  fat  over  the  body,  and  you  can  already  see  the 
difference  in  the  body  of  the  typical  male  and  the  typical  fe- 
male, and  that  difference  progresses  as  they  grow  older.  At 
thirteen  or  fourteen  the  girl  begins  to  menstruate,  but  before 
that  there  is  already  a  marked  difference.  What  made  the 
boy  develop  differently  from  the  girl — already,  before  men- 
struation was  established?    What  did  it? 


390  THE   ENDOCRINES 

The  ovaries  of  that  girl  were  active  and  were  giving  off 
secretion  years  before  she  menstruated.  The  gonads  of  the 
little  boy  were  giving  off  a  secretion  years  before  he  reached 
man's  estate, — and  for  that  reason  the  girl  develops  in  her 
fashion  and  the  boy  in  his.  First  the  ovary  throws  a  different 
secretion  into  the  body  than  do  the  gonads.  But  why?  Be- 
cause in  the  boy,  among  other  things,  the  testicular  extract 
(cells  of  Lej'dig)  stimulates  his  anterior  pituitary  lobe  more 
than  it  does  the  posterior.  In  the  girl,  the  ovarian  secretion 
stimulates  the  posterior  lobe  more  than  it  stimulates  the  an- 
terior; and  inasmuch  as  the  anterior  lobe  has  to  do  with  the 
bony  g-rowth  among  other  things,  his  bony  system  is  heavier 
and  larger  than  that  of  the  girl,  and  the  shape  of  his  pelvis  is 
different  from  that  of  the  girl. 

You  know  what  acromegaly  is, — the  growth  of  the  facial 
bones  and  the  growth  of  the  hands  and  feet  after  full  develop- 
ment has  taken  place;  that  acromegaly  is  due  to  the  anterior 
lobe  hyperactivity.  A  boy  who  at  nineteen  years  of  age  is  six 
feet  or  so  high  is  a  huge  fellow  who  has  had  hyperactivity 
of  the  anterior  pituitary  lobe.  These  are  simply  mentioned 
as  instances  of  excessive  activity.  If  it  is  slightly  more  than 
normal  in  the  growing  boy  than  in  the  growing  girl,  you  have 
your  explanation  of  increased  growth.  When  a  man  develops 
he  has  hair  on  his  face  and  grows  a  beard, — has  hair  on  his 
arms,  chest,  and  legs.  Some  men  are  so  hairy  that  they  sug- 
gest an  orang  outang,  and  you  may  see  a  man  with  greatly 
developed  forearms.  That  man  has  probably  had  a  very 
active  suprarenal  cortex,  but  above  all  he  had  a  very  active  an- 
terior lobe.  Another  man  has  a  very  smooth,  shiny  face;  he 
shaves  only  once  a  week,  and  has  no  hair  on  his  arms  or  legs, 
and  has  a  very  delicate,  sensitive  skin, — shiny,  smooth,  and 
soft.  He  has  not  a  hand  like  mine,  which  is  fairly  broad  with 
a  faint  suggestion  of  acromegaly ;  he  has  long,  tapering  fingers 
like  a  woman.  He  has  had  no  great  activity  on  the  part  of  the 
anterior  lobe;  he  has  a  relatively  greater  activity  of  the 
posterior. 

Then,   when  you  see  a  woman  who  shows  any  of  the 


CLINICS  391 

physical  characteristics  of  the  man,  these  are  produced  partly 
by  the  greater  activity  of  the  man's  gland,  the  anterior  lobe,  in 
many  cases.  When  you  see  a  man  with  effeminate  characteris- 
tics, he  has  the  posterior  pituitary  the  more  predominant,  and 
you  see  how  small  his  hand  is  in  many  cases ;  you  can  see  it  at  a 
glance,  and  say  to  yourself:  this  hand  is  more  of  the  female 
type ;  and  your  mind  goes  back  to  the  gland  responsible  for  one 
or  the  other  condition. 

The  secret  of  all  gland  study  in  the  future  is  to  be  based 
on  these  few  points  that  I  am  telling  you  now.  As  your  skin 
develops,  as  your  hair  develops,  as  your  bones  develop,  as  your 
gastro-intestinal  tract  develops,  all  as  the  result  of  gland  stim- 
ulation, so  does  your  nervous  system  develop  as  the  result  of 
gland  stimulation,  and  so  does  your  mind  develop  as  the  result 
of  gland  stimulation.  While  I  am  directing  your  attention  now 
to  physical  characteristics,  evidenced  by  what  I  can  see  and 
by  what  I  learn  from  menstruation,  from  pregnancy,  from 
miscarriage,  from  dysmenorrhoea, — by  the  same  token  you 
have  innumerable  functional  and  mental  changes  in  individuals 
just  as  much  dependent  upon  gland  anomalies  as  these ;  but  we 
don't  usually  think  of  it  that  way.  If  I  speak  to  you  about 
how  the  thyroid,  the  ovaries,  and  the  pituitary  influence  men- 
struation, I  do  so  because  that  is  my  function  as  a  teacher  of 
gynaecology;  but  as  general  medical  men  we  must  think  of 
all  these  gland  activities  as  influencing  the  whole  range  of  a 
person's  life, — so  that  some  day  we  may  speak  of  a  mental 
dysmenorrhoea  or  a  mental  amenorrhoea,  or  a  mental  mis- 
carriage,— or  repeated  mental  miscarriages.  If  you  like,  you 
can  call  one  a  dementia,  and  the  othe  epilepsy,  and  the  others 
whatever  you  choose.  Do  you  gather  what  I  am  getting  at? 
Supposing  you  call  migraine  a  cerebral  dysmenorrhoea;  it  is 
just  as  good  a  name  as  the  other ;  it  means  the  same  thing  ab- 
solutely. The  idea  of  the  whole  thing  is  to  look  over  every 
patient  from  every  conceivable  point  of  view.  There  is  not 
any  other  field  of  medicine  which  gives  you  the  same  oppor- 
tunity to  find  out  gland  aberrations  as  does  gynaecology,  be- 
cause you  find  out  when  a  girl  first  menstruates,  how  her  men- 


392  THE   ENDOCRINES 

struation  continues,  how  often  she  menstruates,  how  long  her 
menstruation  lasts,  whether  it  is  associated  with  pain,  etc.,  and 
then  comes  the  all  important  point ;  how  many  days  before  she 
menstruates  can  she  tell  that  she  is  going  to  do  so?  There  is 
not  a  heart  murmur  that  tells  you  more  about  the  heart  than 
does  the  answer  to  this  last  question  tell  you  about  a  woman's 
endocrine  makeup. 

If  a  patient  menstruates  at  thirteen  or  fourteen,  men- 
struates regularly,  has  no  pain,  continues  to  menstruate  regu- 
larly, does  not  know  until  she  begins  to  menstruate  that  her 
period  is  due, — she  has  a  very  fine  and  stable  relation  between 
her  endocrines.  The  minute  any  one  of  these  things  is  altered 
or  becomes  abnormal,  there  is  a  hitch  somewhere.  So  far  as 
every  other  function  of  her  body  is  concerned  it  may  be  perfect. 
Your  automobile  may  run  perfectly,  and  yet  there  is  some- 
thing wrong  with  the  tire.  You  can  fix  that;  but  if  there  is 
something  wrong  with  the  mechanism,  you  cannot  fix  it  so 
readily.  So  there  may  be  abnormalities  affecting  a  definite 
region,  and  nothing  else;  or  there  may  be  abnormalities  sug- 
gesting something  wrong  in  many  glands. 

Another  patient  may  tell  you  that  a  week  before  menstrua- 
tion she  has  nervous  upset,  is  cross  with  her  husband,  may  slap 
her  children  only  just  before  menstruation;  then  she  men- 
struates, and  she  is  her  normal  self  again, — then  a  week  be- 
fore the  next  menstruation  comes  the  same  state.  She  may 
menstruate  too  much,  or  normally;  but  if  she  menstruates 
normally  and  has  no  pain,  and  loses  a  normal  amount  of 
blood,  there  may  still  be  a  hitch  somewhere,  and  it  shows  itself 
in  these  premenstrual  phenomena.  They  are  in  most  cases 
temporary,  transient,  premenstrual, — hyperthyroidism  or  hy- 
perpituitarism, but  you  may  have  a  hypothyroidism  in  other 
cases. 

If  you  can  have  these  changes  occurring  a  week  before 
menstruation, — which  changes  are  sometimes  on  the  border 
line  of  mental  disease, — and  if  these  changes  are  due  to  an 
alteration  in  the  glands  brought  about  by  the  premenstrual 
stimulation,  what  prevents  a  patient  from  having  them  for  365 


CLINICS  393 

days  in  the  year, — not  brought  out  every  twenty-eight  days  by 
premenstrual  conditions, — but  a  change  so  permanent  that  it 
is  there  all  the  time?  Do  you  get  what  I  mean?  Therefore 
that  patient  is  for  365  days  of  the  year, — irrespective  of  her 
menstruation, — on  the  border  line,  she  is  psychopathic.  I  men- 
tion these  things  that  you  may  gradually  transfer  your  thoughts 
to  other  phases  of  abnormality  and  prove  that  they  are  due  to 
gland  development. 

Therapeutically  we  come  now  to  one,  or  two,  or  three  of 
the  elements  that  help  us  in  our  cases  of  pituitary  anomaly. 
How  w^ould  you  treat  medically  a  fibromyoma  of  the  uterus 
before  you  operate,  or  one  on  which  you  cannot  operate  or 
where  the  patient  will  not  let  you  operate  ?  Five  or  six  months 
ago  the  wife  of  a  physician  came  to  my  ofifice  with  her  husband, 
who  said  that  his  wife  had  had  a  fibroid  for  several  years,  that 
it  was  growing  larger  and  was  giving  her  a  great  deal  of  pain. 
She  had  a  fibromyomatous  uterus  containing  five  or  six  sep- 
arate fibroids,  reaching  to  the  umbilicus, — reaching  way  over 
to  the  pelvic  brim,  so  that  I  could  not  get  my  fingers  between 
it  and  the  pelvis.  We  could  not  operate  upon  her  because  she 
had  for  many  years  a  cardiac  lesion,  and  at  times  had  to  go  to 
bed  for  a  month  or  so.  Accordingly  I  told  her  husband  that 
we  would  go  ahead  and  treat  her  medically.  So  I  gave  her  a 
capsule  containing  two  drugs,  and  you  know  what  one  of  them 
was, — mammary  extract.  You  know  what  that  does.  Many 
patients  have  a  pain  and  a  contraction  of  the  uterus  every  time 
the  child  suckles  the  breast.  That  result  of  suckling  at  the 
breast  is  not  entirely  a  matter  of  reflex.  There  is  a  secretion 
of  the  gland  itself  which  has  a  tendency  to  contract  the  uterus, 
and  a  woman  who  is  nursing  her  baby  four  weeks  only,  will 
in  nine  cases  out  of  ten  have  her  uterus  back  to  normal  size 
inside  of  that  time.  That  action  of  mammary  extract  is  more 
marked  in  myomata  than  in  fibromata. 

Then  we  gave  her  an  extract  from  the  pituitary  gland. 
What  part  did  I  give  her? 

Ans.    Posterior. 

No.     The  posterior  lobe  stimulates;  that  pituitary  lobe 


394  THE    ENDOCRINES 

makes  the  uterus  grow,  and  was  probably  the  cause  of  the 
myomata  and  possibly  of  the  fibromata.  I  have  shown  you  that 
the  posterior  lobe  is  more  of  a  female  than  a  male  gland ;  the 
anterior  lobe  more  of  a  male  than  a  female  gland ;  in  that  re- 
spect they  are  opposite  in  their  activities,  and  probably  antag- 
onistic, I  gave  her  anterior  lobe.  There  are  no  fibroids  in  the 
male,  but  prostative  enlargements  are  the  same  thing;  so  we 
gave  her  seven  grains  of  mammary  extract,  and  a  grain  or 
two  of  the  anterior  lobe  of  the  pituitary, — and  after  six  months 
there  was  not  a  nodule  in  that  uterus  as  large  as  my  fist.  That 
is  not  only  one  experience;  I  have  had  many  such. 

I  am  not  telling  you  to  treat  all  your  fibroids  as  I  did  that 
case.  I  am  not  beginning  to  say  that  it  is  as  good  as  a  hys- 
terectomy. I  am  telling  you  what  gland  extracts  will  do,  and 
you  can  use  them  in  cases  where  you  don't  want  to  operate, — 
where  the  patient  will  not  let  you  operate,  and  where  you  can't 
operate;  and  if  you  give  these  medicines  for  three  or  four 
months  you  may  often  have  a  uterus  one-third  as  large  as  it 
was,  even  in  that  short  time. 

We  have  not  yet  definitely  come  to  a  conclusion, — but  as 
the  result  of  that  theory,  and  as  the  result  of  the  practice  of 
that  theory,  I  myself  have  come  to  the  conclusion  that  so  far 
as  the  genital  tract  is  concerned,  the  anterior  and  posterior 
lobes  have  totally  different  actions  in  the  female ;  so  that  when 
I  give  mammary  extract  for  this  purpose  (in  myomata)  I 
often  add  the  anterior  lobe.  And  don't  forget  in  this  con- 
nection that  the  anterior  lobe  is  a  wonderful  stimulant. 

When  a  man  at  college  is  the  strong  man  of  his  college 
and  can  throw  a  heavy  weight,  and  can  stand  more  than  any 
of  the  other  thousand  or  three  thousand  students,  he  has 
very  well  developed  active  suprarenals  and  has  a  good  active 
thyroid,  and  he  has  a  very  good  anterior  lobe  of  the  pituitary. 
That  is  a  valuable  cue,  so  that  in  cases  of  asthenia,  where 
patients  are  tired  and  languid,  and  have  low  blood  pressure, 
you  can  often  help  them  a  great  deal  by  giving  suprarenal 
extract  and  the  anterior  lobe  of  the  pituitary, — always,  how- 


CLINICS  395 

ever,  bearing-  in  mind  what  the  latter  may  do  to  the  men- 
struation since  it  antagonizes  the  posterior  lobe. 

Patients  have  come  to  me  suffering  from  menorrhagia, 
bleeding  every  twenty-eight  days  for  eight  days,  and  I  have 
given  them  the  mammary  and  anterior  pituitary  extracts,  and-" 
have  had  them  go  three  months  without  menstruating,  and 
have  then  had  to  give  them  medicine  to  bring  on  a  menstrua- 
tion. This  does  not  act  the  same  way  on  all  patients, — some  of 
these  endocrine  extracts  do.  A  patient  with  myxoedema  or 
with  myxoedematous  symptoms  will  react  readily  under  thy- 
roid and  if  the  increase  in  weight  is  due  to  myxodema  she  will 
lose  in  weight  under  thyroid.  But  you  can  give  some  patients 
huge  doses  of  thyroid  and  it  will  have  no  effect.  If  you  give 
the  right  thing  you  will  get  the  proper  effect ;  if  not,  you  cannot 
expect  it. 

That  much  to  direct  your  attention  to  the  anterior  and 
the  posterior  lobes  and  to  the  theory  of  how  they  act.  The 
problem  for  you  to  help  solve  in  the  future  is  how  to  pick  out 
and  definitely  decide  on  these  symptoms,  other  than  gynaeco- 
logical, which  are  due  to  hyperpituitarism,  for  instance;  and 
you  will  find  many  patients  with  hyperpuitarism  who  simu- 
late a  hyperthyroidism.  The  idea  we  have  in  mind  is  that  if 
mammary  extract  antagonizes  the  previous  stimulation  of  pos- 
terior pituitary  lobe  sufficiently  to  make  a  fibromyoma  atrophy, 
or  sufficiently  to  contract  the  uterus  and  stop  a  menorrhagia, — 
it  may  be  that  it  will  do  the  same  thing  for  that  pituitary  lobe 
in  nervous  conditions  due  to  hyperpituitarism, — and  on  that 
rests  the  greatest  future  for  gland  therapy;  for  that  statement 
brings  us  closer  and  closer  to  the  diseases  of  the  mind, — demen- 
tia precox,  manic  depressive  insanity,  all  the  various  mental 
diseases,  states  of  anxiety,  which  I  believe,  as  surely  as  I  am 
standing  here,  are  every  one  of  them  due  to  a  gland  anomaly 
or  glandular  abnormality, — simply  evidencing  their  phases 
psychically  and  not  physically.  This  study  of  the  physical  stig- 
mata will  enable  you  to  put  your  finger  on  the  gland  or  glands 
at  fault,  and  where  you  have  a  mental  anomaly  associated  with 
a  physical  anomaly,  the  physical  anomaly  may  be  sufficient  to 


396  THE    ENDOCRINES 

direct  your  attention  and  you  will  have  something  to  guide  you 
to  the  gland  or  glands  at  fault. 

At  or  about  the  change  of  life  period  we  have  innumer- 
able mental  changes,  the  vast  majority  of  them  not  pronounced 
enough  to  come  under  the  phase  of  mental  disease  but  sufficient- 
ly pronounced  to  cause  you  to  be  on  the  alert,  and  there  you 
have  something  to  guide  you.  A  patient,  for  instance  a  woman 
of  25  or  30,  suddenly  develops  a  mental  change,  a  psychosis, 
and  her  menstruation  stops.  Some  doctors  will  tell  you  she 
stopped  menstruating  suddenly  and  then  the  psychosis  ap- 
peared,— post  hoc  ergo  propter  hoc, — there  is  the  supposed 
cause.  Does  not  that  same  abnormality  which  affected  her  mind 
also  fail  to  stimulate  the  genital  tract,  and  the  amenorrhoea  and 
the  phychosis  are  due  to  the  same  endocrine  cause.  Changes  at 
or  after  the  change  of  life  period  take  on  sometimes  the  form 
of  melancholia.  Watch  all  these  cases  for  hypothyroidism. 
Many  of  them  will  improve  on  thyroid  extract.  You  may  have 
the  slow  pulse,  the  dry  skin,  the  mental  lack  of  perception,  and 
there  may  be  an  amenorrhoea,  and  you  give  the  patient  thyroid ; 
and  whether  or  not  you  bring  back  the  menstruation  you  are 
supplying  what  the  patient  needs. 

I  believe  that  marked  depression,  this  melancholy  ten- 
dency, rarely  comes  with  hyperthyroidism ;  and  when  you  have 
your  manic  depressive  type,— the  insanity  with  a  manic  type 
for  weeks,  depressive  type  for  a  few  weeks, — who  knows  but 
that  the  changes, — hyperpituitarism  hyperthyroidism  or  hypo- 
pituitarism hypothyroidism — may  not  alternate  ?  For  a  certain 
while  in  many  patients  you  have  menstruation  and  then  amen- 
orrhorea,  your  over  and  then  your  understimulation. 

I  want  you  to  know  what  each  gland  extract  does,  why 
we  use  it  and  what  the  theory  is,  and  if  you  have  a  theory, 
and  it  works  out  in  practice,  the  chances  are  that  it  is  correctly 
founded. 


CHAPTER    XXII 

CASES 

M.  M. 

Seventeen  years  of  age.  Menstruation  at  15  J/2  years,  at 
intervals  varying  from  11  months  to  8  weeks.  Has  had 
whooping  cough,  measles  when  8  years  old,  chickenpox  at  10 
years, — all  slight. 

Complaint:  Pain  on  the  right  side  for  6  months,  and  a 
full  feeling  in  the  stomach  after  eating. 

Rectal  examination:  A  very  small  uterus,  not  much 
larger  than  a  thumb,  much  nearer  the  symphysis  than  normal ; 
unusually  long  utero-sacral  ligaments.  The  patient  is  of  slight 
build,  a  brunette,  physically  active,  and  a  very  bright  student 
at  college. 

Therapy:  Ovarian  extract  5  grs,  thyroid  extract  1/10, 
pituitary  posterior  1/3.    Therapy  began  June  17,  1919. 

The  patient  menstruated  once  in  August  freely  and  once 
in  October,  but  noted  that  she  is  constipated  since  taking  the 
prescription.  For  the  next  few  months  the  pituitary  posterior 
was  omitted  and  ovarian  residue  was  administered.  No  men- 
struation since  then. 

April  29,  1920.     Blood  pressure  100. 

June  10th.  Blood  pressure  100.  The  white  line  on 
scratching  of  the  skin  was  marked,  turning  red  only  very 
slowly. 

Therapy:  Ovarian  extract  5  grs.,  thyroid  1/10  gr.,  pitui- 
tary posterior  1/3  gr. 

June  17th.  Patient  complains  that  after  taking  the  above 
prescription  she  had  for  two  days  and  for  the  first  time  in  her 
life  frontal  headaches.  The  pain  in  the  right  side  has  recurred. 
She  notices  again  that  she  is  constipated  from  taking  the  above 
prescription.  This  last  change  was  likewise  noted  when  the 
same  medication  was  prescribed  in  June,  1919. 

Scratching  of  the  skin  causes  a  white  line,  which  quickly 
becomes  red. 

397 


398  THE    ENDOCRINES 

Rectal  examination :  Uterus  of  the  same  size  as  at  first 
examination;  left  ovary  very  small;  right  ovary  larger  and 
nodular,  and  sensitive. 

In  my  experience  the  most  difficult  field  for  endocrine 
therapy  lies  in  the  field  of  actual  or  relative  amenorrhoea  with 
small  hypoplastic  uteri.  The  same  difficulty  is  observed  in  the 
treatment  of  actual  or  relative  amenorrhoea  associated  with 
atrophy  of  the  uterus,  such  as  is  observed  in  cases  to  which 
we  apply  the  term  dystrophia  adiposogenitalis  or  degeneratio 
adiposogenitalis.  This  case  is  a  dystrophia;  however,  there  is 
not  the  faintest  suggestion  of  adiposity.  From  every  view- 
point the  patient's  thyroid  is  functionating  normally.  If  the 
posterior  pituitary  is  at  fault  there  is  certainly  no  inclination 
to  the  taking  on  of  fat.  The  ovaries  are  hypoplastic,  and  we 
must  place  the  blame  on  their  lack  of  secretory  activity,  with 
a  lack  of  ovulation.  The  suprarenal  g-lands  are  probably  at 
fault.  I  should  say  from  my  observation  that  the  so-called 
female  glands,  having  reference,  in  addition  to  the  ovaries,  to 
the  posterior  pituitary  and  the  adrenal  medulla,  are  insufficient. 
There  is  probably  a  predominance  of  function  on  the  part  of 
the  anterior  pituitary  and  the  adrenal  cortex.  It  would  be  in- 
teresting to  note  the  effect  of  large  doses  of  corpus  luteum. 


May  5,  1920. 
MRS.  H.  F. 

Married  10  years,  0  para;  curettage  3  years  ago. 

Menstruation  began  at  14  regular,  duration  3  days. 

Her  menstruation  now  occurs  regularly,  growing  grad- 
ually less  since  the  curettage  and  for  the  past  year  is  only  a 
slight  stain. 

Husband's  specimen  is  normal. 

Complaint :  Headaches,  amenorrhea,  and  gain  in  weight 
of  over  thirty  pounds  since  the  curettage. 

Examination :     Small  uterus. 

Therapy :     Ovarian,  thyroid,  ov.  residue,  post,  pituitary. 

July.     Menstruation  improving. 


CASES  399 

March  15.  1920. 
B.  M.  (Single)  37  yrs.  old 

Menstruation  began  at  13  years. 

Menstruation  regular,  5  days'  duration.  For  the  last  2 
months  has  menstruated  every  2  weeks,  and  very  profusely. 

Premenstrual  pain  in  the  legs ;  headaches,  irritability ; 
mother  had  same  symptoms  before  menstruation,  and  in  her 
case  the  menopause  developed  at  53  years. 

Had  measles,  whooping-cough,  croup  and  frequent  sore 
throats. 

Sleeps  well,  dreams  little,  "lack  of  pep,"  passes  more  urine 
before  each  menstruation;  has  a  drawing  feeling  along  the 
front  of  the  right  leg ;  hands  and  feet  cold. 

Chief  complaint:   Headaches  (3  years)  and  menorrhagia. 

Examination,  rectal :     Pelvis  normal. 

Blood  pressure  140. 

Therapy:  Mammary,  thymus,  thyroid  1/6,  placenta  3 
grains. 

April  17,  1920.  Patient  had  begun  to  bleed  on  April  6th; 
under  the  above  medication  she  menstruated  very  little.  Head- 
aches have  not  disappeared. 

April  26th.    Improved  in  every  way.    Blood  pressure  130. 

May  21st.  Headache  practically  gone.  Menstruation 
normal. 


April  5,  1920. 
A.  L. 

Menstruation  17  years.     Q.  28  days;  5  days,  much  pain. 

Menstruation  began  at  13  years.  Regular;  no  pain  at 
that  time. 

Patient  had  measles,  whooping-cough  and  scarlatina  at 
1 0  years  of  age. 

Has  had  "spells"  after  menstruation,  only  once  between 
menstruation.  They  occur  at  night,  always.  The  muscles  of 
her  face  move,  but  she  does  not  bite  her  tongue.  For  two 
years  knew  nothing  of  them,  but  since  she  is  at  boarding 
school  she  realizes  their  periodicity.     She  recognizes  an  attack 


400  THE    ENDOCRINES 

because  "she  wakes  up  tired  and  drowsy."  Her  bowels  are 
normal,  she  sleeps  well,  plays  tennis  and  basket  ball,  and  is 
otherwise  normal. 

Examination,  per  rectum,  shows  nothing  abnormal.  Her 
thyroid  appears  enlarged;  no  suggestion  of  trichosis. 

Therapy:     Mammary,  thymus. 

April  19,  1920.    Mammary,  thymus. 

May  3.  Menstruated  April  28,  4  days  late  (due  to  mam- 
mary and  thymus),  with  slight  dysmenorrhora. 

Therapy:  Mammary,  thymus,  placenta  and  ovarian 
residue. 

May  17.    Has  had  no  attacks.    Pressure  115,  pulse  76. 

June  21.  Menstruation  May  25.  Pressure  105.  Per- 
fectly well.     Therapy:     As  of  May  3. 

Patient  had  no  attacks  while  under  my  care,  but  on  return- 
ing to  her  home  in  North  Carolina  developed  the  same  attacks. 


May  13,  1920. 
E.  R. 

Twenty-five  years  of  age. 

Menstruation  began  at  16  Q.  3  weeks,  later  Q.  4  weeks. 

Menstruation  now  Q.  3  weeks,  6  days'  duration,  losing 
much  blood,  little  pain. 

Once  had  an  amenorrhea  of  2  months  and  one  of  3  months. 

Premenstrual  phenomena,  none. 

Had  measles,  chickenpox  and  whooping  cough. 

Diphtheria  at  18  years  of  age,  and  had  3  injections  of 
anti-toxin. 

After  her  attack  of  diphtheria  she  went  to  school  and 
found  herself  behind  her  class;  then  had  an  attack  of  grippe 
and  finally  left  school. 

After  she  left  school  she  noticed  that  food  went  slowly 
into  her  stomach.  She  was  in  hospital  for  weeks;  diagnosis 
of  "cardiac  orifice  spasm," 

Operated  on  twice :  one,  stretching  of  oesophagus ;  two, 
intra-oesophageal  "cutting." 

She  is  troubled  with  dreams  of  fearful  nature;  is  afraid 


CASES  401 

she  is  "going  to  do  something"  to  herself;  is  afraid  she  is 
"going  crazy." 

She  has  no  moles,  but  acquired  freckles  2  years  ago. 

She  blushes  readily;  states  she  is  bashful  and  self-con- 
scious. 

Red  line  reaction  of  the  skin  is  marked. 

Rectal  examination  shows  several  small  fibroids  in  an- 
terior wall.     Pressure  120. 

Therapy:     Mammary,  thymus,  placental. 

May  11.    Pressure  115,  pulse  90. 

Therapy:  Mammary,  thymus,  placental,  thyroid. 

May  28.     Pressure  110. 

Therapy :    Continued. 

June  1.     Patient  much  improved.     Menorrhagia  better. 

Spasm  on  swallowing  is  vastly  better. 


May  18,  1920. 
L.  M. 

Fifteen  years  of  age. 

Menstruation  began  at  13  years.  Q.  3  months. 

Menstruation  now  Q.  2  to  3  months,  duration  1  week; 
loses  much  blood;  slight  pain. 

Premenstrual  phenomena:  Headache,  nervous,  twitches, 
irritable. 

Is  large  for  her  years,  plump,  rosy  cheeked,  smooth  skin, 
blushes  readily,  no  hair  on  arms  or  legs. 

Takes  long  to  fall  asleep.  Sleeps  poorly;  has  dreams 
which  frighten  her;  has  nightmares,  and  dreams  often  of 
snakes. 

Two  years  ago  was  in  camp  in  the  woods  and  boys  often 
brought  in  dead  snakes. 

As  a  child  disliked  Grimm's  Fairy  Tales  and  Little  Red 
Riding  Hood. 

Was  formerly  good  in  school  and  in  her  studies,  but  now 
cannot  memorize.     She  is  tired  and  languid. 

All  these  different  things  came  on  since  the  establishment 

of  her  menstruation. 
26 


402  THE    ENDOCRINES 

Had  measles,  mumps,  chickenpox  and  scarlatina. 

Four  years  ago  had  a  lump  in  her  breast  and  her  family- 
were  greatly  concerned  over  it,  but  it  has  since  disappeared. 

Had  ear  trouble  during  the  winter;  has  always  been 
subject  to  colds,  which  are  accompanied  by  swollen  glands  of 
the  neck;  has  headaches  over  the  eyes;  her  hands  are  always 
cold,  though  moist. 

She  is  at  boarding  school,  plays  tennis  and  basketball,  does 
Grecian  dancing,  takes  violin  lessons  and  formerly  took  piano 
lessons.  Is  not  talented  in  music  and  finds  practicing  extremely 
irksome. 

She  has  a  domineering,  aggressive  mother,  who  wants  to 
make  her  adept  in  all  the  so-called  modern  accomplishments. 

Her  main  complaint  when  speaking  to  me,  in  the  presence 
of  her  aunt  who  understands  the  patient  well,  is  that  she  is 
always  tired  and  cannot  memorize. 

Blood  pressure  130. 

Diagnosis  :  Pituitary  posterior  plus ;  anterior  pituitary 
and  thyroid  and  suprarenal  cortex  minus. 

Therapy :  Ovarian  extract,  thyroid,  suprarenal  extract, 
placental. 

This  case  is  extremely  suggestive  of  a  type  of  girl  who, 
because  of  her  pituitary  anomaly,  and  because  of  the  absence 
of  proper  understanding  at  home,  can  readily  approach  the 
type  of  Mrs.  Sp.  (page  454). 


May  12,  1920. 
MRS.  L. 

Twenty  years  old,  married  4  years,  no  para,  two  artificial 
abortions,  the  last  2  years  ago. 

Menstruation  began  at  14  years,  regular,  duration  6  days, 
large  flow,  marked  dysmenorrhea. 

Of  late  flows  for  3  days,  but  loses  a  large  amount  of  blood. 

For  4  years  has  had  "stomach  trouble"  with  occasional 
attacks  of  very  severe  pain  accompanied  by  vomiting,  and  was 
told  she  had  ulcer  of  the  stomach. 

Premenstrual    phenomena :      Four   days'   bearing   down, 


CASES  403 

nervous,  erratic  and  restless.  Feels,  as  she  describes  it,  ex- 
tremely "scoldy,"  and  on  the  second  day  of  menstruation  feels 
better. 

For  the  last  3  months  has  headaches,  chiefly  occipital,  and 
running  down  the  spine.    The  right  thigh  is  very  sensitive. 

Examination :  Cystic  ovary ;  the  whole  right  side  is  ex- 
tremely sensitive,  especially  in  the  region  of  the  right  kidney 
and  gall  bladder. 

Therapy :   Placental  g.  iii,  thyroid  g.  1/6,  suprarenal  g.  ii. 

May  19.     Pain  gone.     Pressure  120,  pulse  88. 

May  28.  Therapy :  Continued.  Condition,  both  physical 
and  mental,  remarkably  improved. 


MRS.  E. 

Married  10  years;  2  para,  last  3  years  ago;  first  labor  in- 
strumental; nursed  2^^  months;  1  curettage. 

Menstruation  regular,  7  days'  duration,  much  blood,  al- 
ways so. 

Had  whooping  cough  and  measles  and  mumps  when  19 
years  of  age. 

Symptoms :  Pain  in  both  ovarian  regions,  backache  and 
menorrhagia. 

Examination :  Sclerosis  of  left  broad  ligament,  due  to 
cervical  laceration ;  ren  mobilis  sinistra. 

Therapy :    Mammary,  thymus,  suprarenal. 

March  16,  1920.  Pain  in  both  sides  better;  felt  pain 
through  region  of  diaphragm  for  4  days  after  taking  pre- 
scription and  voided  more  urine,  especially  at  night. 

To  overcome  the  action  of  the  posterior  pituitary,  partly 
responsible  for  the  menorrhagia  and  for  possible  pyloric  irri- 
tation, she  was  given  ovarian  extract,  thyroid,  suprarenal, 
pituitary  anterior. 

April  6,  1920.  Patient  feels  better;  menstruation  much 
less  in  amount. 

A  small  intramuscular  lump  in  the  upper  part  of  left  rec- 
tus which  was  present  at  first  examination  has  become  much 


404  THE   ENDOCRINES 

smaller.     Since  taking  prescription  she  observes  "itching  of 
the  skin." 

]\Iay  20,  1920.     Patient  feels  better,  stronger  and  "alto- 
gether different."     Same  medication  continued. 


March  11,  1920. 
A.  W. 

Twenty-seven  years  of  age.  Unmarried.  Menstruation 
began  at  12,  occurring  7  to  8  times  a  year. 

Menstruation  now  O.  6  weeks  to  3  months,  3  days'  dura- 
tion. Has  a  dark  brown  discharge  for  4  days  preceding  loss 
of  blood.  Has  severe  dysmenorrhea.  AH  women  of  her 
family  suffer  from  dysmenorrhea. 

She  is  short,  has  a  pretty  doll-like  face  and  excellent 
color. 

Was  always  plump,  and  3  years  ago  weighed  140  pounds; 
now  weighs  190. 

Has  had  diphtheria,  whooping  cough,  scarlet  fever  and 
attacks  of  "appendicitis." 

She  has  a  little  hair  on  the  chin,  linea  alba,  and  on  the 
sciatic  surface  of  her  legs. 

Complaint:     Dysmenorrhea  and  pain  on  the  right  side. 

Examination:  Uterus  small,  and  retroverted,  corpus  lu- 
teum  cyst  of  right  ovary.  Blood  pressure  130.  Patient  is 
very  emotional;  libido  is  marked. 

This  patient  has  all  outward  characteristics  of  posterior 
pituitary  minus  with  probable  plus  of  adrenal  cortex.  She  is 
typical  of  many  cases  of  obesity  with  small  uterus  and  irregular 
menstruation.  It  is  more  than  probable  that  posterior  pituitary 
minus,  while  responsible  for  some  cases  of  dystrophia  adiposo 
genitalis,  finds  its  counterpart  in  symptoms  of  the  same  or  sug- 
gestive type  and  yet  the  condition  is  due  to  posterior  pituitary 
plus.    The  corpus  luteum  cyst  is  of  importance. 

Therapy:     Ovarian  extract  and  thyroid. 

Patient  menstruated  on  ]\Iarch  20th  and  again  on  May 
8th.  Dysmenorrhea  absent.  No  change  in  weight.  Blood 
pressure  120,  pulse  80. 


CASES  405 

December  13,  1919. 
MISS  B. 

First  menstruation  at  14.    Regular,  normal,  no  pain. 

Menorrhagia  began  3  or  4  years  ago  and  then  improved. 

Always  increased  by  swimming  or  exercise.  For  the  last 
3  months  menstruation  lasts  5  days;  is  increased  in  amounts 
with  many  clots. 

Complains  of  pain  in  the  right  side  and  backache. 

Rectal  examination  shows  everything  normal  except  a 
slightly  enlarged  right  ovary. 

Therapy:  Mammary  extract,  grains  10,  three  times  a 
day  was  administered  with  prompt  and  excellent  results. 


June  23,  1919. 
MISS  B. 
First  menstruation  at  14  years.    Menstruation  Q  35  days; 
3  days'  duration,  pains. 

Premenstrual :    Severe  pain  in  the  head. 
Chief  complaint :     Backache  and  dysmenorrhea. 
Therapy :    Ovarian  extract  and  thyroid. 
After  4  months  her  reply  was,  menstruation  comes  every 
30  days  and  is  absolutely  painless. 


April  6,  1920. 
B.  M. 

Thirty-seven  years  of  age.  Menstruation  began  at  13 
years ;  regular ;  5  days'  duration ;  excessive  flow  with  clots ; 
marked  headaches  worse  at  menstruation  for  the  last  3  years. 
For  the  last  two  months  has  been  menstruating  every  two 
weeks. 

Premenstrual  phenomena :  Pain  in  the  legs,  headaches, 
irritable.  This  irritability  has  always  been  present.  Her 
mother,  whose  menstruation  ceased  at  53  years,  always  com- 
plained of  the  same  annoyance.  The  patient  sleeps  well,  dreams 
little,  passes  urine  more  frequently  before  each  menstruation; 
takes  an  occasional  cathartic.  She  complains  of  "lack  of  pep," 
of  a  drawing  feeling  along  the  thigh  of  the  right  leg,  and  of 
cold  hands  and  feet. 


406  THE   ENDOCRINES 

Rectal  examination :    Normal. 
Blood  pressure  140. 

Therapy:  Placenta  3  grs.,  thyroid  1/6,  mammary  5 
grs.,  thymus  3  grs. 

April  17th.  Menstruation  began  on  April  7th;  the  medi- 
cation was  taken  during  menstruation,  which,  however,  was 
much  diminished.     Headache  persisted  during  menstruation. 

April  26th.     Blood  pressure  130;  same  medication. 

May  21st.  Patient  menstruated  on  May  6th,  after  an 
interval  of  nearly  5  weeks;  duration  5  days,  but  slight.  The 
headaches  between  menstruations  are  much  better,  but  have 
not  entirely  disappeared  during  the  menstruation.  Patient 
remarked  that  since  taking  the  medication  she  needs  no 
cathartic. 

June  17th.  Patient  menstruated  on  June  8th,  but  only 
for  one  day.  Her  headaches  are  practically  gone.  She  feels 
stronger  in  every  way  and  wishes  to  renew  her  former  athletic 
activities.     Blood  pressure  118. 

In  this  patient  the  menorrhagia,  which  has  persisted  for 
years,  and  the  headaches,  which  have  come  on  in  the  last  three 
years  and  which  became  extremely  marked  during  the  pre- 
menstrual and  menstrual  periods,  are  referred  to  overactivity 
of  the  posterior  pituitary.  The  cold  hands  and  feet,  the  lack 
of  energy,  and  the  blood  pressure  of  140  are  to  be  referred  to 
a  moderate  degree  of  hypothyroidism;  this  combination  of 
thyoid  minus  and  posterior  pituitary  plus  is,  in  my  opinion, 
one  of  the  most  frequent  combinations  in  the  way  of  endocrine 
abberation  to  be  noted  in  women.  It  is  especially  frequent 
during  the  climacterium,  and  is,  in  my  opinion,  the  most  fre- 
quent cause  of  high  blood  pressure,  especially  at  that  period. 
As  I  have  mentioned  so  often,  the  posterior  pituitary  is  re- 
lated to  the  development  of  fibroids,  certain  cases  of  glycosuria, 
and  to  many  of  the  varying  grades  of  pyschic  deviations. 
Overactivity  of  this  lobe  of  the  pituitary  is  directly  related  in 
many  cases  to  exaggerated  libido.  While  we  are  only  in  the 
early  stages  of  our  knowledge  concerning  the  manifestations 


CASES  407 

of  endocrine  conditions,  the  association  of  cervical  polyp*., 
of  gallstones  and  of  renal  calculi,  with  other  physical  mani- 
festations of  posterior  pituitary  overactivity  appears  to  me 
to  be  more  than  accidental.  That  an  overactivity  of  the  pos- 
terior pituitary  associated,  for  instance,  with  a  hyperactive 
thyroid,  on  the  one  hand, — and  a  hypoactive  thyroid  on  the 
other  hand,  should  produce  different  manifestations.,  is  to  be 
expected.  When  the  added  role  of  the  suprarenals,  thymus, 
parathyroid,  gonads,  and  other  glands,  is  taken  into  consid- 
eration, the  variations  in  the  clinical  manifestations  and  in 
the  types  of  disturbances  may  be  readily  granted. 


March  12,  1920. 
MISS  S.  G.  (Sister  of  Mrs.  B.  F.,  p.  420) 

Nineteen  years  of  age.  Tall,  excellent  figure,  well  pro- 
portioned. 

Menstruation  at  14  years,  q.  3  to  4  weeks,  3  days,  no  pain. 

Menstruation  now  q.  3^2  weeks,  lasting  2j/^  days  for  the 
last  year,  whereas  during  the  two  preceding  years  it  lasted  5 
days.  She  has  gained  progressively  in  weight.  Each  year 
as  her  menstruation  has  grown  less  in  amount  she  has  gained 
in  weight  up  to  166  pounds. 

There  is  the  faintest  suggestion  of  hair  on  the  upper  lip, 
but  face,  arms,  thighs,  etc.,  free  of  any  hair. 

Examination:     Rectal;  uterus  while  not  enlarged  has  a 

fibroid  nodule. 

While  the  anterior  and  post,  lobes  of  the  pituitary  are 
both  excellent,  the  post,  is  apparently  a  little  minus  in  its 
balance. 

Therapy:    Ovarian  extract  and  thyroid. 

The  first  miscarriage  and  the  early  deliveries  of  her  sister, 
Mrs.  B.  F.,  are  an  evidence  in  the  latter  of  post,  pituitary  activ- 
ity during  pregnancy.  Both  girls,  like  their  mother,  are  broad 
and  thick  chested,  healthy,  and  Mrs.  F.  from  her  features,  nose 
and  teeth  had  an  unusually  good  anterior  pituitary. 


408  THE    ENDOCRINES 

April  30,  1920. 
B.  M.   (Single) 

Menstruation  regular,  2  to  3  days,  no  pain. 

Premenstrual  lasting  ten  days;  fullness  in  the  breasts;  a 
strained  feeling  of  tension  in  the  pelvis ;  irritability. 

Headaches  before  menstruation,  both  frontal  and  occipital. 

Is  extremely  short-sighted  and  has  double  vision. 

Complaint :  A  lump  in  the  right  breast  which  gets  larger 
before  each  menstruation,     (Fibroma-adenoma.) 

Rectal  examination  :     Pelvis  normal. 

Pulse  100;  pressure  120. 

Blushes  readily ;  has  numerous  fine  varicosities  of  the  leg. 

The  slightest  blow  on  any  part  of  her  body  causes  "black 
and  blue  spots." 

Has  a  twin  sister  with  the  same  ocular  trouble. 

Both  had  measles,  chicken-pox  and  mumps  at  the  same 
time;  had  scarlatina  at  different  times. 

The  twin  sister  suffered  for  a  long  period  from  eczema 
and  "burst  a  blood  vessel  in  her  eye." 

Both  are  very  near-sighted  with  "muscular  trouble"  in- 
volving the  muscles  of  the  eye. 

Both  have  numerous  varicosities  of  the  lower  extremities. 

The  twin  sister  was  operated  on  for  fibroid  of  the  uterus ; 
previous  to  operation  she  suffered  from  severe  dysmenorrhea, 
and  severe  occipital  headaches,  which  have  disappeared  since 
the  operation. 

Diagnosis :    Thyroid  plus,  pituitary  posterior  plus. 

Therapy:    Mammary,  thymus,  placenta. 


November  20,  1919. 
MRS.  R.  P. 
Married  2  years ;  0  para,  0  abort.,  0  operation. 
Menstruation  Q,  3  weeks,  duration  3  days,  no  pain. 
Complaint :     Sterility. 
Examination:    Acute  retroflexion. 
Therapy :     Ovarian  extract  and  thyroid  extract. 


CASES  409 

December  5th.  Specimen  of  husband  normal  as  to  sper- 
matazoa. 

Menstruation  December  23rd,  which  was  a  week  late. 

January  26th,  Has  not  yet  menstruated,  but  has  men- 
strual pain,  that  is,  a  sensation  as  if  she  was  going  to  men- 
struate. 

Therapy :  I.  Placental  extract,  thyroid,  stypticin.  2. 
Rectal  suppositories  containing  1/3  gr.  of  opium  and  1/3  gr.  of 
belladonna  used  each  night  before  retiring. 

February  11th.    No  menstruation  as  yet. 

March  15th.  Patient  is  gravid,  and  has  been  turned  over 
to  her  family  physician. 


July  23,  1919. 
MRS.  A.  A. 

Married  14  months.  Menstruation  regular,  5  days'  dura- 
tion.   Dysmenorrhea  for  2  hours. 

Examination :  Acute  retroflexion  easily  replaced  by  pes- 
sary. 

Complaint :    Why  not  gravid  ? 

Therapy :    Ovarian  extract,  plus  thyroid. 

Last  menstruation  August  25,  1919. 

Therapy :  Thyroid  extract,  plus  stypticin,  plus  sodium 
bromide.  Suppositories  of  opium  and  belladonna  given  for 
3  days  corresponding  to  what  would  have  been  each  men- 
strual period. 

Reason  for  the  above  was  the  menstruation  of  5  days' 
duration  and  the  dysmenorrhea.  The  patient's  tall  stature, 
general  appearance  and  the  just  mentioned  signs  spoke  for 
post,  pituitary  excess. 

Is  gravid.    Delivered  June  2,  1920. 


December  8,  1919. 
MRS.  L. 
Married  20  months.     Precautions  15  months.     Menstrua- 
tion regular,  3  days,  no  pain. 

Five  months  after  marriage  she  flowed  once  between  2 


410  THE   ENDOCRINES 

menstruations  after  bathing  in  the  ocean.  This  was  followed 
by  menorrhagia  for  4  months. 

Complaint:    Why  not  gravid? 

Examination :  Retrodisplacement ;  cervical  leucorrhea, 
not  mucoid. 

Card  marked  "doubtful  prognosis." 

Therapy :     Ovarian  extract  and  thyroid. 

January  16th.  Last  menstruation  December  12,  1919. 
Was  next  due  January  9th. 

January  30,  1920,  Is  3  weeks  over  her  period.  In  view 
of  the  history  of  menorrhagia  was  given  placental,  plus  thy- 
roid, plus  stypticin.  Each  month  she  felt  as  if  she  were  going 
to  menstruate. 

March  12,  1920.  First  examination  since  she  went  over 
her  period.  Is  gravid;  has  a  fibroid  the  size  of  a  walnut  on 
the  anterior  wall  of  the  uterus. 

Therapy :     Placental,  plus  thyroid. 


March  28th. 
MRS.  K. 

Married  4  years;  0  para;  precautions  for  only  a  few 
months. 

Eight  months  ago  miscarried  at  2^^  months. 

Menstruates  regularly,  but  only  for  2  days,  up  to  the  last 
few  months. 

She  had  a  menstruation  on  January  15th  and  then  one  on 
March  14th. 

There  was  marked  male  type  of  hair  distribution,  and  the 
card  reads  "therefore  give  pituitary  post."  On  March  18th 
she  was  given  ovarian  extract,  plus  thyroid,  plus  pituitary 
post. 

She  menstruated  on  April  18th,  which  was  her  last  men- 
struation. 

On  June  28th,  after  having  spotted,  she  was  given  thy- 
roid plus  stypticin.  Shortly  after  this  she  ceased  her  visits 
and  was  delivered  in  January  by  another  physician. 


CASES  411 

September  24.  1919. 
MRS.  B. 

Married  2^/^  years;  1  abort.,  2  years  and  2  months  ago. 
No  curetting. 

Menstruation  q.  31  days,  5  days'  duration;  pain. 

Premenstrual :     Dizzy,  stomach  upset. 

Complains  of  pain  in  the  right  side  and  in  the  rectum, 
backache.     Frequent  urination  by  day. 

Complaint:    Why  not  gravid? 

Diagnosis  :    Apparently  O.  K. 

Therapy :     Ovarian  extract  and  thyroid. 

The  card  says :     This  is  given  because  of  delayed  men- 
struation, but  one  week  before  menstruation  give  thyroid  only. 

October  10th,    Gave  thyroid  and  stypticin. 

This  alternation  of  treatment  was  kept  up  for  2  months. 
Patient  continued  treatment  in  her  home  in  Panama. 

A  letter  received  from  Panama  states  that  the  patient  is 
3  months  pregnant. 


January  24,  1918, 
MRS.  A.  C. 

Married  2  years.  Menstruation  regular  before  marriage. 
Subsequently  amenorrhea  for  3  months,  then  for  5  months, 
then  for  a  year.  Last  menstruation  was  brought  on  after 
hypodermics  of  corpus  luteum  administered  by  her  physician. 
In  noting  the  characteristics  of  this  patient,  the  history  recalls, 
among  the  physical  signs,  trichosis  of  the  chest,  back,  thighs. 
Viewed  from  the  standpoint  of  the  endocrines,  the  diagnosis 
was  pituitary  anterior  plus,  adrenals  (cortex)  plus,  pituitary 
posterior  minus,  ovarian  secretions  minus. 

Examination :     Small  uterus,  small  ovaries. 

January  29th.  A  hypodermic  of  pituitrin  produced  no 
reaction. 

January  30th.  A  hypodermic  of  ovarian  residue  pro- 
duced no  reaction. 

January  31st.     A  hypodermic  of  adrenalin  made  the  pa- 


412  THE   ENDOCRINES 

tient  feel  weak,  caused  her  to  become  pale,  and  the  cardiac 
palpitation  was  noticeable. 

Therapy:  Ovarian  extract  7  gr.,  thyroid  extract  l^  gr., 
posterior  pituitary  1  gr.,  in  capsules  3  times  a  day. 

The  patient  began  to  menstruate  after  6  weeks,  and  there- 
after menstruation  recurred  every  6  weeks,  lasting  4  days. 

December  30,  1918.  Examination  shows  the  ovaries  and 
uterus  to  be  apparently  normal. 

June  14,  1920.  This  patient,  who  lives  in  Philadelphia, 
announced  to  me,  through  a  patient  whom  she  referred  to  be- 
cause of  sterility,  that  a  baby  had  been  born  to  her  in  March, 
1920. 


August  28,  1916. 
MRS.  L.  M.  C. 

Married  June  15,  1916.  Menstruation  previously  regu- 
lar.   Last  menstruation  June  26,  1916,  lasting  only  1  day. 

August  28,  1916.    Diagnosis:    Pregnancy. 

Life  November  14,  1916. 

The  delivery  in  this  patient  was  an  exceedingly  long  and 
tedious  one,  during  which  small  doses  of  pituitrin  (2  minims) 
were  given.    At  least  20  hypodermics  were  administered. 

July  25,  1918.  Patient  complains  of  dysmenorrhea  a 
week  before  menstruation  and  of  menorrhagia  lasting  5  days. 

Therapy:    Ovarian  extract,  plus  thymus,  plus  suprarenal. 

September,  1919.  Ovarian  extract,  plus  thyroid,  plus 
pituitary  whole  gland,  because  she  desires  to  become  pregnant. 

February  19,  1919.  Patient  wishes  to  know  why  she  does 
not  become  pregnant  as  she  has  been  anxious  to  for  several 
months. 

Therapy:     Ovarian  extract,  plus  thyroid. 

March  19,  1919.  Ovarian  extract,  plus  ovarian  residue, 
plus  hypodermics  of  ovarian  residue. 

June  4,  1919.    Thyroid  extract,  plus  suprarenal. 

Last  menstruation  June  26,  1919. 

Delivered  April  7,  1920. 


CASES  413 

May  8,  1919. 
MRS.  P. 

Married  3  years.     Precautions  2  years ;  0  para, ;  0  abort, ; 
0  op. 

Menstruation  Q  30  days-40  days,  5  days'  duration;  pro- 
fuse, with  pain. 

Premenstrual :    One  week ;  pain  in  the  legs ;  sense  of  bear- 
ing down ;  irritable.    Last  menstruation  April  25th 

Has  gained  30  pounds  in  a  few  months. 

Diagnosis :    Uterine  adenoids. 

Therapy :     Ovarian  extract  and  thyroid. 

Patient  conceived  at  once.    Has  been  delivered  of  a  baby. 


October  1.  1919. 
MRS.  A.  K. 

Married  2  years ;  1  miss,  one  year  ago  at  2  months.  Men- 
struation regular,  duration  1  week.    Dysmenorrhea. 

Complaint:    Why  not  gravid? 

Examination:    Cystic  left  ovary. 

Therapy:  Ovarian  extract  gr.  7,  thyroid  extract  gr. 
1/6  T.  I.  D, 

Patient  menstruated  on  October  9th,  Amenorrhea  since 
then.  Life  felt  February  15th.  Her  pregnancy  has  taken  a 
normal  course. 


MRS,  M, 

Married  13  years;  2  para,  second  5^  years  ago. 

Menstruation  Q,  21  days,  5  days'  duration,  no  pain,  nor- 
mal amount. 

Complaint :  Headaches  and  sleeplessness.  For  the  latter 
veronal  had  been  used. 

Examination :    Normal. 

Diagnosis:     Posterior  pituitary  overactivity. 

Therapy :    Placental  Ext.  g.  iii,  t.  i.  d. 

Shortly  after  taking  the  above  prescription  there  was  a 
marked  improvement,  the  patient  sleeping  without  the  use  of 


414  THE    ENDOCRINES 

any  veronal.  Menstruation  came  on  May  5th,  which  is  the 
first  time  in  months  that  the  menstruation  interval  was  as 
long  as  28  days. 

This  case,  as  do  many  others,  instances  the  not  infrequent 
effect  of  placental  extract  in  delaying  menstruation,  even  when 
the  interval  is  of  normal  duration  and  especial!}^  so  when  the 
interval  is  short.  I  attribute  this  action  to  the  inhibition  which 
the  placenta  physiologically  exerts  on  the  posterior  pituitary. 
It  is  the  inability  on  the  part  of  the  thyroid,  corpus  luteum, 
and  the  trophoblast  cells  of  the  impregnated  ovum  to  inhibit 
the  menstrual  stimulus  of  the  posterior  pituitary  which  ac- 
counts for  very  many  cases  of  sterility.  Fecundation  takes 
place  but  nidation  progresses  only  slightly  and  the  microscopic 
ovum  is  cast  off  by  menstruation.  This  menstruation  occurs 
at  the  normal  time  or  may  be  delayed  from  2  to  10  days.  Those 
sterile  patients,  Avho  are  treated  by  ovarian  extract,  ovarian 
residue,  thyroid,  etc.,  should  normally  menstruate  at  the  regu- 
lar time,  or  even  a  day  or  two  earlier.  If  with  such  therapy 
a  patient  occasionally  goes  two  or  more  days  over  her  period, 
it  may  be  judged  that  fecundation  and  an  attempt  at  nidation 
have  taken  place.  Many  patients,  with  a  normal  menstrual 
interval,  go  from  2  to  10  days  over  their  period,  1  or  2  or  3 
times  a  year. 

When  such  a  history  is  given,  the  possibility,  in  fact,  the 
probability,  of  the  earliest  form  of  miscarriage  should  be  taken 
into  consideration.  Judging  from  the  effect  that  placental  ex- 
tract has  evidenced  in  several  hundred  cases,  it  Is  the  best  of 
all  the  extracts  in  this  type  of  sterility.  It  may,  of  course,  be 
combined  with  any  other  of  the  gland  extracts  which  are  in- 
dicated for  the  purpose  of  delaying  or  diminishing  menstrua- 
tion, excessive  menstruation  or  irregular  uterine  bleedings  in 
other  conditions  than  those  treated  for  sterilitv. 


December  20,  1919. 
MRS.  E.  O. 
Married  7  years;  0  para,  0  abort.,  0  op. 
First  menstruation  at  13  years  of  age.     Menstruation  q. 


CASES  415 

5  weeks  at  first,  now  q.  4  weeks.     Last  menstruation  Novem- 
ber 2d,,  1919. 

Complaint:  Why  not  gravid?  (Precautions  for  6 
years. ) 

Examination  :  Normal  uterus  with  whistle  cervix.  Tiny 
fibroid  on  the  anterior  wall.     Both  ovaries  cystic. 

Therapy :     Ovarian  extract  and  thyroid. 

Last  intercourse  December  29,  1919.  Last  menstruation 
December  30,  1919. 

January  9,  1920.  Patient  stated  that  she  began  the  medi- 
cation again  one  day  after  her  menstruation  was  over  and 
started  to  bleed  again. 

Note  made  on  January  9,  1920,  states  :  "One  week  before 
her  next  expected  menstruation  I  ought  to  change  the  medi- 
cation because  she  menstruates  for  7  days." 

•  January  23,  1920.  Patient  was  given  placental,  plus  thy- 
roid for  1  week.  She  went  over  her  period  and  I  considered 
her  pregnant,  but  made  no  examination. 

February  22,  1920.  Patient  commenced  to  bleed  and  in 
spite  of  therapy  she  had  a  profuse  menstruation,  expelled 
several  large  clots  and  was  given  ergotol  in  repeated  doses. 
She  was  kept  in  bed  for  7  days  without  examination  or  any 
attempt  at  curettage. 

March  3,  1920.  Patient  was  examined,  found  to  be  nor- 
mal, and  was  given  thyroid  extract  grain  l/6th,  t.  i.  d. 

It  might  be  thought  that  this  patient  was  not  pregnant. 
At  any  rate,  one  is  compelled  to  say  that  after  the  administra- 
tion of  placental  extract  and  thyroid  she  went  over  her  period 
due  on  January  30,  1920,  until  her  bleeding  and  probable  mis- 
carriage of  February  22,  1920. 


June  23,  1919. 
MRS.  S. 
Married  6^   years ;    1    miscarriage,   6  years ;    1   para,  4 
years.     Menstruation  regular,  3   days'  duration,  slight  pain. 
Patient  stated  that  her  womb  was  "out  of  place"  when  she  con- 
sulted a  physician  several  years  ago;  that  he  "straightened" 


416  THE    ENDOCRINES 

the  womb  with  a  pessary  and  that  she  then  became  pregnant. 

Examination :     Normal. 

Complaint :    Why  not  gravid  again  ? 

Therapy:  Ovarian  extract,  grs.  7;  thyroid  extract,  gr. 
1/6. 

Last  menstruation  occurred  August  30th. 

November  11th,  Patient  began  to  spot  and  stain.  In 
spite  of  rest  in  bed  and  the  administration  of  thyroid  extract 
and  the  use  of  suppositories  of  extract  of  opium  gr.  1/3,  ex- 
tract of  belladonna  gr.  1/3,  the  patient  miscarried. 

The  patient  was  not  curetted. 

November  21st,    Mammary  extract,  grs,  10,  t,  i.  d, 

January  14,  1920,  Because  of  excessive  menstruation 
mammary  extract,  grs.  10,  and  thyroid,  grs.  1/6,  t,  i.  d, 

February  16th.     Patient  is  again  anxious  to  conceive. 

Therapy:  Ovarian  extract,  grs.  7;  thyroid  extract,  gr. 
1/10. 

May    12th.      Ovarian   extract,    grs.    7;    thyroid   extract, 

gr.  M- 

May  26th.  As  the  patient  anticipates  her  menstruation 
the  1st  of  June,  thyroid  extract,  gr.  ^,  and  placental  extract, 
grs.  3,  are  prescribed. 

June  11th.     Patient  is  a  week  over  her  period. 

Therapy :  Thyroid  extract,  gr.  %  ;  corpus  luteum,  grs. 
3 ;  placental  extract,  grs.  3. 

This  patient  has  been  wearing  a  pessary  since  her  mis- 
carriage of  November,  1919.  She  belongs  to  the  class  where 
nidation  does  not  take  place  readily.  This  process  must  be 
aided  by  the  administration  of  endocrines  which  aid  nidation 
and  prevent  the  menstrual  stimulus  from  expelling  the  fecun- 
dated ovum.  This  patient  has  had  two  miscarriages  and  in 
each  of  the  two  instances  that  she  has  become  pregnant,  while 
under  my  observation,  ovarian  extract  and  thyroid  were  given 
as  a  preliminary  treatment.  Based  on  the  experience  of  her 
miscarriage  of  November,  she  is  taking  placental  extract,  cor- 
pus luteum  and  thyroid  to  aid  in  the  continued  nidation  and 
to  ward  off  the  menstrual  stimulus  which  in  many  patients  is 


CASES  417 

noted  during  many  or  all  the  months  of  pregnancy.  If  this 
recurrent  attempt  to  menstruate  can  be  warded  off  till  "life"  is 
felt,  the  prospects  of  a  successful  termination  are  most  promis- 
ing. The  therapy  is  to  be  continued  up  to  the  stage  of  seven 
and  a  half  or  eight  full  months. 


May  4,  1919. 
MRS.  J.  S. 

Married  2  years;  0  para,  1  abort,  one  year  ago,  having 
been  curetted  when  2  weeks  over  period. 

May  4,  1919.  Menstruation  previously  every  26  days,  5 
days'  duration;  premenstrual  annoyance  3  days,  consisting  of 
pain  in  the  breasts.  Is  nauseated,  urinates  often  and  men- 
struated last  on  March  10th.  On  May  15th  she  began  to  spot, 
suffered  from  uterine  cramps  and  then  expelled  large  clots. 
She  was  given  ergotol  for  4  days  when  her  bleeding  ceased. 
Patient  was  told  that  in  all  probability  her  uterus  was  entirely 
free  of  the  ovum  and  that  no  curetting  would  be  needed.  She 
was  quite  astounded  as  her  mother  and  all  her  friends  had 
never  heard  of  a  miscarriage  having  been  treated  except  by 
curettage.  In  10  days  she  was  up  and  about  and  during  the 
summer  was  given  ovarian  extract  and  thyroid  extract.  At 
each  visit  the  patient  recounted  the  surprise  of  all  her  friends 
and  the  numerous  physicians  whom  she  met  that  she  had  not 
yet  been  curetted. 

Her  last  menstruation  occurred  on  October  30th. 

December  15th.  Therapy:  Thyroid  extract,  plus  placen- 
tal, plus  stypticin.  At  each  period  corresponding  to  her  men- 
struation patient  suffered  from  cramps  and  felt  as  if  she  were 
going  to  menstruate.  She  was  kept  in  bed  for  several  days 
during  each  of  these  periods,  during  which  days  she  was  given. 
in  addition  to  the  above  capsules,  suppositories  containing  1/3 
grain  of  opium  and  1/3  grain  of  belladonna. 

March  12,  1920.  First  examination  since  she  became 
pregnant.  Uterus  normal  in  position,  patient  feels  life.  Above 
methods  will  be  continued  until  she  is  delivered. 


418  THE    ENDOCRINES 

MRS.  P. 

Married  3  years ;  0  para.  Last  menstruation  January  20th. 

Examination:  April  8,  1920.  Diagnosis,  pregnancy, 
acute  retroflexion. 

Patient  is  advised  to  spend  2  hours  every  day  flat  on  her 
■  face  and  to  sleep  as  much  as  possible  in  that  position. 

The  only  noticeable  features  are  varicosities  and  varicose 
veins  on  leg,  which  have  been  present  for  years. 

Patient  has  been  seen  every  2  weeks.  Her  only  complaint 
was  constipation. 

Therapy:  May  12,  1920.  Thyroid  extract  gn  1/6, 
sodium  bicarb,  gr.  10,  phenolphthalein  gr.  1/3  gr.  t.  i.  d. 

June  9th.  Has  cramps  as  if  she  was  going  to  be  unwell 
and  has  a  spotting  of  bright  red  blood. 

Therapy:  Rest  in  bed,  capsules  of  placental  extract  gr. 
3  and  thyroid  extract  gr.  1/6  q.  4  hours;  suppositories  of  opium 
gr.  1/3  and  belladonna  gr.  1/2  at  night. 

July  20th.    Pregnancy  uninterrupted. 


January  12,  1920. 
MRS.  B.  G. 

Married  7  years;  1  para.  5  years  ago;  instrumental  de- 
livery. Menstruation  regular,  duration  2  days.  Has  gained 
35  pounds  since  her  baby  was  born. 

Complaint :  Pain  on  the  right  and  left  side,  backache. 
Anxious  to  become  gravid  again. 

Examination :  Acute  anteflexion  and  enlarged  and  sensi- 
tive right  ovary. 

Last  menstruation  January  3rd. 

Therapy:    Ovarian  extract  gr.  7,  thyroid  extract  gr.  1/6. 

February  9th.  Is  now  1  week  overdue;  complains  of 
pain  in  the  right  side. 

Note:     Did  the  ovum  come  from  the  right  ovary? 

February  25,  1920.  Nausea  marked.  Occasional  uterine 
cramp. 

Therapy:  Thyroid  extract  1/6,  stypticin  gr.  1^,  in  cap- 
sules t.  i.  d. 


CASES  419 

The  left  breast  discharged  colostrum  continuously.  Pa- 
tient states  that  the  left  breast  "leaked"  for  4  months  during 
her  first  pregnancy. 

April  7th.  Therapy:  Thyroid  extract  1/6,  corpus  lu- 
teum  gr.  7  t.  i.  d. 

Patient  complains  that  her  hands  and  legs  feel  swollen. 

There  is  no  oedema  or  pitting.    Urine  normal. 

May  7th.    Blood  pressure  110. 

Therapy:    Thyroid  extract  continued. 


MRS.  F. 

One  para.  4  years  ago.  During  this  first  pregnancy  she 
spotted  during  the  first  4  months  at  what  would  have  been  3 
menstrual  periods. 

Two  years  subsequently  the  patient  miscarried  in  the  sec- 
ond month  of  pregnancy;  was  curetted  because  of  excessive 
bleeding.  On  several  occasions  mammary  extract  and  ergotin 
have  been  administered  for  menorrhagia.  Patient  became 
pregnant  for  the  third  time,  last  menstruation  occurring  on 
January  22,  1920. 

February  18th.    Patient  had  cramps  and  spotted  for  1  day. 

Therapy :    Placental  extract  gr.  3,  thyroid  extract  gr.  1/6. 

April  14th.     Cramps  again.     Therapy  continued. 

June  11th.    Blood  pressure  135. 

Therapy:  Thyroid  extract  1/6  t.  i.  d.,  which  will  be  con- 
tinued until  delivery.  The  thyroid  extract  aids  in  the  nesting 
of  the  ovum,  inhibits  overactivity  of  the  posterior  pituitary  and 
is  indicated  whenever  the  blood  pressure  in  a  pregnant  patient 
is  over  120. 


December  9,  1919, 
MRS.  K. 
Married  7  months.     Menstruation  regular.     Dysmenor- 
rhea. 

Last  menstruation,  October  27th,  was  less  than  usual  in 
amount.  Slight  bleeding  was  noted  in  December  and  in 
January. 


420  THE    ENDOCRINES 

When  examined  on  December  9th,  the  patient  was  preg- 
nant, but  the  uterus  seemed  larger  than  expected  if  October 
27th  were  the  last  normal  menstruation. 

Patient  spotted  and  stained  December  20th. 

Therapy:  Placental  extract  gr.  3,  stypticin  gr.  1^^  t.  i.  d. 
Suppositories  of  opium  and  belladonna. 

Murphy  drip  containing  5  per  cent,  glucose  and  2  per 
cent,  sodium  bicarb,  given  daily  for  the  marked  nausea. 

March  22nd.  Has  cramps  of  the  type  experienced  in  the 
dysmenorrhea.     Same  therapy  was  observed. 

This  patient  belongs  to  that  type  in  whom  the  menstrual 
stimulus  is  unusually  marked  during  pregnancy.  Therapy  Is 
based  on  the  theory  of  overactivity  of  the  posterior  pituitary 
gland. 


MRS.  A.  F. 

Married  8  years ;  1  para.  7  years  ago. 

Abdominal  ligament  suspension  for  retroflexio  mobilis  2 
years  ago. 

Complaint:    Headaches  and  dysmenorrhea. 

Last  menstruation  March  1,  1920. 

May  10th  patient  noted  a  slight  stain  of  blood,  with  a 
feeling  as  if  she  was  going  to  be  unwell. 

No  examination. 

Therapy :  Placental  extract  gr.  3,  thyroid  extract  gr.  1/6 
in  capsule  form  q.  4  hours. 

Rectal  suppositories  extract  of  opium  gr.  1/3,  extract  of 
belladonna  gr.  1/3  t.  i.  d. 

After  5  days  in  bed  patient  was  gradually  permitted  to 
resume  her  usual  routine  and  was  warned  that  a  like  experience 
was  possible  every  28  days  during  her  pregnancy. 


June  15,  1915. 
MRS.  B.  F. 
(One  of  the  proofs  of  the  therapeutic  action  of 
anterior  pituitary) 
Married  2  years;  0  para.     Last  menstruation  February 
7th.     Life  felt  July  2nd. 


CASES  421 

This  patient  miscarried  when  6^/2  months  pregnant. 

December  4,  1915.  Was  given  thyroid  extract  grain 
1/10,  plus  arsenious  acid  l/30th,  plus  bichloride  of  mercury 
grain  1/100,  plus  oxalate  cerium  grains  5,  in  capsule  form 
T.  I.  D.    This  was  continued  for  months. 

January  11,  1916.  Last  menstruation.  Was  given  bich- 
loride of  mercury  1/1 00th,  arsenious  acid  l/30th,  thyroid 
extract  1/1 0th,  plus  stypticin  grains  2,  in  capsule  form  T.  I.  D. 

September  27,  1916.    Delivered  of  a  baby  girl. 

June  27,  1919.     Pregnant;  last  menstruation  April  25th. 

Therapy:  Bichloride  1/lOOth,  plus  thyroid  1/lOth,  plus 
arsenious  acid  l/30th,  plus  oxalate  of  cerium. 

Life  September  10th.    Delivery  January  17th. 

February  20,  1920.  After  a  severe  influenza,  during 
which  she  did  not  nurse  her  baby,  she  was  given  suprarenal 
extract,  plus  whole  pituitary  gland.  She  resumed  nursing. 
She  began  to  spot. 

March  5,  1920.  Because  of  the  spotting  she  was  given 
suprarenal  extract  and  pituitary  anterior. 

March  12,  1920.  Feels  perfectly  well;  spotting  has 
stopped.     Patient  has  an  active  pit.  post. 


August  25,  1919. 
MRS.  L.  C.  H. 

]\Iarried  2  years. 

Menstruation  regular,  O  28  days;  5  days'  duration. 

Last  menstruation  June  11,  1919.     Gravid. 

The  physician  who  sent  her  to  me  stated  that  her  husband 
had  a  Wasserman  plus. 

Therapy:  Thyroid  extract  grain  1/10,  plus  bichloride  of 
mercury  grain  1/1 00th,  plus  arsenious  acid  grain  l/30th,  plus 
oxalate  of  cerium  grains  5. 

This  was  taken  3  times  a  day  throughout  her  pregnancy 
and  has  for  many  years  been  my  therapy  for  all  cases  of  re- 
peated miscarriage  with  Wasserman  plus,  and  for  all  cases 
where  to  my  knowledge  the  husband  is  Wasserman  plus. 

Delivery  at  normal  date.     Perfectly  healthy  baby. 


422  THE   ENDOCRINES 

January  17,  1918. 
MRS.  W. 
Married  October  28,  1917,    Last  menstruation  November 
11,  1917.    Slight  nausea.    Has  previously  taken  specific  treat- 
ment, but  informs  me  that  the  last  Wasserman  is  negative. 
Examination :     Gravid. 

Is  given  thyroid  1/1 0th,  plus  bichloride  of  mercury 
1 /100th,  plus  arsenious  acid  l/30th,  plus  oxalate  of  cerium 
grains  5. 

Patient  miscarried  after  spotting  for  1  week  when  preg- 
nant 3  months. 

December  10,  1919.  Patient  reports  that  her  menstrua- 
tion was  October  30,  1919. 

March  10,  1920.  Therapy:  Thyroid  1/lOth,  plus  bi- 
chloride of  mercury  1/lOOth,  plus  arsenious  acid  l/30th,  plus 
oxalate  of  cerium  grains  5. 

Patient  is  normally  gravid.  The  medication  has  been 
continued  and  is  to  be  continued  until  delivery.     Normal  baby. 


February,  1920. 
E.  M. 

Unmarried.     Complains  for  3  years  of  menorrhagia. 

Examination:     Uterus  enlarged. 

Therapy:     Mammary  extract,  grs.  10  T.  I.  D. 

After  taking  this  prescription  there  was  for  the  first  time 
an  amenorrhea  of  3  months,  followed  by  a  menstruation,  asso- 
ciated with  the  loss  of  a  very  large  amount  of  blood.  During 
this  menstruation  patient  again  took  the  mammary  extract. 
When  seen  on  June  9th  she  was  quite  pale,  complained  of 
flushing.     Pulse  108,  blood  pressure  145. 

Examination:  Round  hard  fibroid  larger  than  a  navel 
orange  fills  the  upper  part  of  the  vagina  with  Its  pedicle  ex- 
tending up  the  cervix.  As  the  patient  is  unable  to  go  to  the 
hospital  at  the  present  time  she  is  given  mammary  extract  7 
grs.,  thymus  3  grs.,  Blaud's  mass  3  grs.,  in  capsule  form  t.  i.  d. 

Tune  24th.    Fibroma  removed. 


CASES  423 

January,  1920. 
F.  G. 

Married  21  years;  3  para.,  the  last  six  years  ago. 

Menstruation  O.  3  weeks  for  the  last  5  years;  duration 
7  days;  large  amount  of  blood  lost. 

Examination :    Enlarged  uterus. 

Diagnosis :     Fibrosis  uteri. 

Therapy :     Mammary  extract. 

March  15th.  Patient  has  been  spotting  almost  continually 
for  several  weeks. 

Examination :  A  round  hard  fibroma,  the  size  of  an 
apple,  is  in  the  vagina,  its  pedicle  extending  up  a  distance  of 
nearly  2  inches  into  the  uterus. 

Operation :  Removal  of  the  fibroma,  the  base  of  the 
pedicle  being  readily  reached  through  the  greatly  dilated  cer- 
vix. Thorough  curettage.  During  her  stay  in  the  hospital 
patient  was  given  mammary  extract. 

April  19,  1920.  Uterus  normal  in  size;  blood  pressure  140. 

Therapy:    Thyroid,  gr.  1/6  t.  i.  d. 

June  16th.  Blood  pressure  148;  no  reduction  in  blood 
pressure  after  administration  of  thyroid, 

Therapy:    Mammary  extract,  thymus,  placenta. 

Not  only  have  ergotin,  likewise  stypticin,  been  replaced  by 
mammary  ext.  in  the  forms  of  menorrhagia  and  metrorrhagia 
associated  with  enlarged  uterus,  but  the  added  value  is  noted  in 
the  not  so  infrequent  expulsion  and  delivery  through  the  cer- 
vix of  unrecognized  submucous  fibromyomatous  tumors.  (See 
previous  case.) 


MRS.  J.  W. 

Two  para.,  the  last  12  years  ago. 

Last  menstruation  May  15,  1918.  Complains  of  nausea, 
pain  in  the  breasts,  pressure  on  the  bladder. 

June  28,  1919.  Examination:  Patient  is  gravid.  The 
uterus,  however,  is  the  size  of  a  10  weeks'  pregnancy,  feeling 
almost  like  a  double  uterus  or  possibly  a  twin  pregnancy. 

From  the  6th  month  on  it  was  quite  apparent  that  there 


424  THE   ENDOCRINES 

were  numerous  myomata  which  could  be  readily  felt  by  the 
external  hands. 

The  patient  was  delivered  after  two  false  alarms,  each 
of  which  began  with  pain,  lasting  for  several  hours,  and  then, 
gradually  diminishing. 

Examination  two  weeks  after  delivery  show^ed  the 
uterus  to  be  very  much  enlarged  and  more  than  eight  distinct 
nodules,  varying  from  the  size  of  a  large  marble  to  a  small 
apple,  were  readily  palpated. 

Immediately  after  labor  the  patient  had  been  given  ergotol 
y2  dram.,  Q.  3  hours.  This  was  now  replaced  by  mammary 
extract,  gr.  x,  ergotin  gr.  1.5,  pituitary  anterior,  grs.  2,  in  cap- 
sule form.  At  the  end  of  eight  weeks  the  uterus  was  of  nor- 
mal size,  with  scarcely  a  nodule  to  be  outlined  by  the  examin- 
ing fingers. 

This  disappearance  of  myomata  in  the  post  partum  period 
in  patients  who  nurse  the  baby  is  by  no  means  an  infrequent 
occurrence,  and  is  probably  overlooked  many  times  because 
no  examinations  are  made.  In  those  patients  who  do  not 
nurse  their  babies,  and  even  in  those  who  even  though  nursing 
spot  and  stain  at  irregular  periods,  the  administration  of  mam- 
mary extract  is  a  very  valuable  and  rational  procedure. 


February  11,  1920. 
MRS.S. 

Married  14  years;  0  para.;  1  abort.  10  years  ago  at  the 
10th  week.     No  operation. 

Menstruation  began  at  13  years,  regular;  one  week  dura- 
tion; large  amount. 

When  married  the  patient  weighed  160  pounds.  Within 
the  first  year  after  marriage  she  attained  her  present  weight 
of  200  pounds.  She  is  tall,  broad-shouldered,  her  fat  is  well 
distributed ;  has  a  very  rosy  complexion. 

Complaint :  Menorrhagia,  pain  in  the  left  side,  pain  be- 
tween the  shoulder  blades,  frequency  of  urination. 

Examination :  Uterus  contains  two  large  fibroids  and  is 
the  size  of  a  3  months'  pregnancy. 


CASES  425 

Therapy :     Mammary  extract. 

March  15,  1920.  Her  menstruation  of  March  1st  was  of 
7  days'  duration,  but  less  in  amount. 

Therapy :     Mammary  extract  and  pituitary  whole  gland. 

April  12th.     The  uterus  is  decidedly  smaller. 

Therapy :    Mammary,  thymus,  pituitary  whole  gland. 

May  3rd.  The  fibromyoma  in  the  right  horn  is  much 
smaller. 

Therapy :    Mammary,  thymus,  placenta. 

May  19th.  Patient  complains  of  haemorrhoids  which 
have  appeared  in  the  last  3  weeks. 

June  16th.  Blood  pressure  130.  Uterus  not  one-half 
the  size  noted  at  first  examination. 

Therapy :     Mammary,  thymus,  placenta,  suprarenal. 


March  23,  1920. 
MRS.  G.  L. 

Married  10  years;  0  para.,  no  abort.,  no  op.;  curetted  at 
18  for  dysmenorrhea. 

Menstruation  began  at  12.  q.  3^  weeks,  lasting  four  tq 
six  days. 

For  the  past  six  months  she  loses  very  much  more  blood, 
passing  very  large  clots. 

Premenstrual :    Marked  irritability. 

Complaint :     Headache  and  menorrhagia. 

Diagnosis :    Fibromyoma,  size  of  three  months. 

Therapy :    Mammary  g  x — thymus  gr.  v. 

April  6th.  Menstruation  came  at  the  expected  time;  pa- 
tient suffered  great  pain  from  the  clots ;  bleeding  lasted  longer 
but  was  less  in  amount.  The  size  of  the  tumor  was  quite  re- 
duced. Prescription  was  continued  during  menstruation,  as 
it  is  probable  that  it  acts  best  at  that  time. 

Therapy :  Mammary  g  x — thymus  gr.  v,  thyroid  g  1/6. 

April  14th.  Patient  stained  slightly  for  one  day.  Has 
noticed  palpitation  and  constipation. 

Therapy:     Mammary,  thymus,  thyroid,  suprarenal. 


426  THE    ENDOCRINES 

April  21st.  Is  constipated  since  taking  her  medicine  and 
tumor  appears  a  little  larger. 

Therapy:     Mammary,  thymus,  placental. 

April  30th.  Menstruation  appeared  on  April  23rd  with 
a  loss  of  much  blood. 

Therapy:    Mammary,  thymus,  thyroid,  iron  and  arsenic. 

I  advised  a  curettage  and  subsequent  endocrine  medica- 
tion. Submucous  fibroids  do  not  cease  bleeding  on  the  above 
therapy,  but  they  may  be  extruded  as  a  consequence  of  medi- 
cation. 


February  25,  1920. 
MISS  E.  O. 

Forty  years  old.     Menstruation  regular,  3  days. 

Associated  with  frontal  headache,  pain  in  the  right  side, 
drawing  in  the  legs. 

Premenstrual  (1  week),  "dragged  out,  headachy,  de- 
pressed, cries  easily." 

Pain  in  the  right  side;  always  worse  at  menstruation. 

Obstipated;  pain  in  back  and  rectum. 

Reddish  leucorrhea  for  1  year. 

Burning  urination  during  menstruation. 

Hands  cold ;  sleeps  poorly ;  wakes  up  several  times  a  night 
and  continually  thinks  about  her  sister  who  was  ill  of  an  incur- 
able disease  for  many  months  and  who  had  since  died. 

Has  grayish  streaks  in  her  hair. 

Eyes  and  face  and  expression  are  those  of  melancholic 
depression. 

Examination :  Fibroid  in  the  right  horn  of  the  uterus ; 
right  ovary  enlarged;  pulse  slow;  pressure  130. 

Amount  of  urine  excreted  in  24  hours,  3  pints. 

Medication :  Suprarenal  extract,  plus  thyroid,  plus  pla- 
centa. 

March  4th.     Much  improved,  sleeps  better,  pressure  110. 

June  30th.     Fibromyoma  has  absolutely  disappeared. 


CASES  427 

September  7,  1919. 
MRS.  S. 

Married  12  years;  2  para,  the  last  7  years  ago.  Nursed 
for  4  months.  Curetted  twice,  the  last  time  August  25,  1919,. 
because  she  was  over  her  period  and  presumably  pregnant. 

Some  premenstrual  annoyance  1  week.  Menstruation  q. 
24  days. 

Complaint :  Pain  on  the  left  side.  Headaches  plus  vom- 
iting almost  every  week.  This  annoyance  developed  after  her 
first  labor. 

Examination :  Uterus  enlarged  with  1  fibroid  the  size 
of  a  hickory  nut. 

Therapy :     Pituitary  post,  given  for  diagnostic  purposes. 

October  9,  1919:  Patient  reports  that  she  has  had  bear- 
ing down  pains ;  that  the  medication  acts  on  her  bowels  and 
bladder.     Fibroid  seems  larger. 

Note:     (Pituitary  post,  is  causing  growth). 

Therapy :     Pituitary  whole  gland. 

March  5,  1920.  Fibroid  larger,  left  ovary  distinctly 
cystic. 

Therapy:    Mammary  extract,  plus  thymus. 

March  17,  1920.  Headaches  and  vomiting  gone.  Last 
menstruation  occurred  on  February  16,  1920.  As  the  patient 
is  always  4  days  ahead  of  time  she  thinks  she  may  be  preg- 
nant, and  has  cramp-like  feeling  as  if  she  were  going  to  be. 

Therapy:     Ovarian  extract  plus  thyroid. 

April  23rd.  Last  menstruations  occurred  March  18th 
and  April  13th. 

May  21st.     Therapy:     Mammary,  thyroid  and  placenta. 

June.  Uterus  shows  scarcely  a  sign  of  fibromyomatous 
nodule.    Headaches  and  nausea  gone. 


May  19,  1920. 

MRS.  H. 

Married  21  years;  4  para,  last  6  years  ago;  2  aborts.,  last 
10  years  ago. 


428  THE    ENDOCRINKS 

Nursed  each  of  children  for  9  months.  During  lactation 
there  was  amenorrhea  for  8  months. 

Five  years  ago  curettage  and  plastic. 

Menstruation  began  at  12  years,  q.  4  weeks,  3  days. 

Premenstrual  phenomena :  Headaches,  nervousness,  last- 
ing one  week. 

For  past  6  years  menstruation  q.  3  weeks,  duration  6 
days,  loses  much  blood. 

Complaint :  Pain  in  the  right  side,  headache,  menor- 
rhagia,  loss  of  weight  and  anaemia  (hmglobin  60). 

For  several  years  suffered  from  gallstone  colics  which 
usually  occurred  during  menstruation.  Once  had  -slight  attack 
of  jaundice  and  x-ray  ordered  some  months  ago  by  family 
physician  showed  stone  in  gall  bladder. 

Pressure  130,  pulse  84. 

Examination  :    Small  fibroid  in  right  horn. 

Her  mother  is  70  years  old  and  has  diabetes. 

Patient  was  referred  to  me  because  this  suggestion  had 
been  made  that  she  should  be  curetted,  and  then  receive  radium 
treatment  to  bring  about  a  cessation  of  menstruation.  Since 
such  treatment  causes  atrophy  of  the  ovaries,  I  advised  curet- 
tage and  endocrine  therapy. 


May  26,  1920. 
MISS  C. 

Twenty-five  years  of  age.  Unmarried.  Menstruation 
began  at  12^^  years.     Regular. 

Has  always  lost  a  fair  amount  of  blood  at  menstruation. 
Has  always  suffered  from  dysmenorrhea,  which  is  worse  dur- 
ing the  last  4  months. 

She  suffers  from  headaches,  which  are  premenstrual. 

She  has  had  diphtheria  and  pneumonia. 

Her  mother  underwent  a  hysterectomy  for  fibroid  and 
later  an  emergency  operation  for  gallstones.  A  sister  of  this 
patient  has  a  fibroid,  became  pregnant,  and  had  a  miscarriage. 
This  sister  is  now  suffering  from  diabetes. 

Examination :     Fibroids  of  the  uterus,  intramural  and  a 


CASES  429 

large  subperitoneal  fibroid  of  the  left  horn.  Blood  pressure 
140. 

This  case,  which  I  saw  in  consultation  with  her  family 
physician,  was  interesting  from  standpoint  of  family  history, 
not  overlooking  the  diabetes  in  the  sister  of  this  patient.  The 
patient  had  been  given  corpus  luteum  by  her  physician.  I 
suggested  the  addition  of  mammary  extract.  While  much  may 
be  accomplished  with  the  intramural  fibroids  little  can  be  ex- 
pected from  endocrine  therapy  as  regards  the  subperitoneal 
tumors. 

Subsequent  operation  showed  both  myomata  and  fibro- 
mata. 


May  28,  1920. 
MRS.    R. 

Married  2  years,  for  the  second  time ;  1  para  5  years  ago 
by  her  first  husband. 

Menstruation  began  at  16;  regular.  For  the  past  year 
menstruation  occurred  every  three  weeks,  5  days'  duration, 
scanty  in  amount.  Has  always  menstruated  scantily.  She  is 
irritable,  depressed,  cries  easily ;  whenever  she  becomes  excited 
her  "menstruation  comes  on."  Seventeen  years  ago  she  had  a 
severe  attack  of  pneumonia. 

Examination :  Uterus  is  enlarged,  containing  several 
fibromyomata,  the  one  in  the  right  horn  as  large  as  an  apple, 
not  firm  in  consistency.  Blood  pressure  140,  pulse  62.  She 
has,  however,  occasional  attacks  of  tachycardia.  She  is  tall, 
well  built,  with  prominent  bulging  eyes.  She  complains  of 
hemorrhoids,  and  has  marked  varicose  veins. 

Therapy :  Placental  extract,  grs.  3 ;  thyroid  extract,  gr. 
1/6;  ovarian  residue,  grs.  5. 

The  placental  extract  is  given  to  antagonize  the  posterior 
pituitary  which  is  held  responsible  for  the  fibromyomatous 
uterus;  the  thyroid  is  given  because  of  the  slow  pulse;  the 
ovarian  residue  is  given  because  of  the  relative  amenorrhea. 

June  18th.  Patient  states  that  she  feels  better  in  every 
way;  blood  pressure  128,  pulse  62. 


430  THE    ENDOCRINES 

Therapy :  Mammary  extract,  grs.  7 ;  thymus  extract,  grs. 
3 ;  thyroid  extract,  gr.  1/6. 

The  mammary  and  thymus  are  given  for  their  direct 
effect  upon  the  fibromyomatous  uterus.  This  prescription  and 
the  one  given  on  May  28th  will  be  used  alternately  at  various 
times  in  the  hope  that  the  menstruation  may  take  place  every 
4  weeks  and  that  the  uterus  will,  as  is  confidently  expected,  re- 
turn within  3  to  4  months  to  practically  normal  size.  The 
fibromyomatous  uteri,  not  associated  with  menorrhagia  or 
metrorrhagia,  that  is  with  no  submucous  tumors,  are  favor- 
able to  endocrine  treatment.  Those  tumors  which  are  subperi- 
toneal and  are  fibromatous  and  not  myomatous  are  not  so 
readily  affected.  In  several  cases  they  were  brought  to  the 
surface  and  become  more  prominent,  even  though  the  uterus 
itself  diminished  markedly  in  size.  Only  the  future  will  decide 
whether,  as  I  believe,  the  anterior  and  posterior  lobes  of  the 
pituitary  are  related  to  fibromata  and  to  myomata  respectively. 
The  plan  which  I  am  following  now  of  using  placental  extract 
in  many  of  these  cases  bears  in  mind  this  possibility,  that  while 
placental  extract  inhibits  the  posterior  pituitary  it  may  stimu- 
late the  anterior  pituitary, — hence  the  value  of  combining 
mammary  extract,  as  a  rule,  when  placental  extract  is  given. 
Placental  extract  inhibiting  further  stimulation  by  the  pituitary 
posterior;  mammary  extract  contracting  the  uterus  and,  pos- 
sibly, exerting  an  inhibitory  influence  on  the  pituitary  likewise. 


May  12,  1920. 
MRS.  M. 

Married  five  and  one-half  years.     0  para. 

Menstruation  began  at  12  q.  4  to  8  weeks.  Menstrua- 
tion subsequently  came  on  q.  2,  4,  6  months. 

Three  years  ago  after  a  fall,  and  an  amenorrhea  of  2 
months,  she  bled  profusely  and  her  physician  said  she  had  a 
miscarriage.  Since  then  she  menstruates  less  in  amount  and 
has  gained  30  pounds  in  weight. 

Her  last  menstruation  was  on  January  27th  and  on  April 
22nd  she  stained  slightly. 


CASES  43 1 

Patient  has  hair  on  chin  and  upper  lip,  thigh  and  legs. 

Blushes  readily,  and  so  does  her  mother,  who  has  a  blood 
pressure  of  160  and  suffers  from  cervical  polyps. 

Examination :     Small  uterus. 

Therapy:     Ovarian,  thyroid,  placenta. 
MRS.  C. 

April  14,  1920.  Mrs.  C,  mother  of  above  patient,  Mrs.  M, 

Married  28  years,   7  para  the  last   11   years,  no  abort., 
0  op. 

Last  menstruation  March  3rd,  duration  10  days. 

Complaint :     Pain  in  the  right  side,  backache,  excessive 
flow  during  the  last  2  menstruations. 

Examination :    Cystic  right  ovary,  cervical  polyps. 

Blood  pressure  160. 

Therapy  :     Mammary  and  thymus. 

May  12,  1920.     Blood  pressure  150. 

Therapy:     Mammary,  thymus. 

April  27,  1920.     Mammary,  thymus,  thyroid. 

IMay  26.     Pressure  140,  purse  90. 

Therapy  :     Placenta  and  thyroid. 

The  polyps  will  be  removed  by  curettage. 


May  12,  1920. 
MRS.  D.  C. 

Married  27  years;  2  para  (17  years),  2  abort.  (19  years). 

Menstruation  regular,  4  days'  duration  up  to  7  weeks  ago, 
since  which  time  the  patient  spots  almost  continually. 

Since  the  development  of  this  symptom  she  has  occipital 
headaches,  pain  in  the  left  knee  and  left  arm. 

She  ordinarily  voids  little  urine,  but  for  the  last  few 
weeks  is  disturbed  at  night  by  the  desire  to  void. 

Examination :     Small  cer\ical  polyp. 

Therapy:    Mammary,  thymus,  placenta. 

I  view  cervical  polyps  and  overgrown  endometrium  as 
an  evidence  of  overstimulation  by  the  posterior  pituitary. 
These  rarely  respond  to  any  treatment  except  curettage. 


432  THE   ENDOCRINES 

February  20th. 
MRS.  J.  B. 

Married  4  years ;  0  para,  1  abortion  three  years  ago  at  8 
weeks. 

Menstruation  regular;  2  days;  pain. 

Premenstrual  symptoms  last  for  10  days;  pain,  head- 
aches, nervousness,  tired;  feels  like  lying  down  all  the  time. 
These  symptoms  are  more  marked  since  the  abortion,  especially 
for  the  last  year. 

Dysmenorrhea  of  late. 

Urinates  often  by  day  and  night. 

Weight  about  the  same. 

Headaches  much  worse  during  the  last  year. 

Markedly  frigid. 

When  married  had  losses  in  the  family  and  felt  "heart- 
broken." 

Is  not  young  and  expresses  the  opinion  that  this  may  have 
to  do  with  her  frigidity. 

She  was  given  ovarian  extract  (whole  gland)  and  thyroid 
extract. 

Pituitary  extract  post,  was  marked  on  the  card  as  the 
indicated  drug  awaiting  an  answer  as  the  amount  of  urine 
passed  in  the  succeeding  24  hours. 

She  reported  the  next  day  that  she  passed  5}^  pints  in 
24  hours. 

A  minus  of  the  post,  pituitary  is  thus  suggested  by 
her  general  symptoms  and  by  the  relative  diabetes  insipidus. 


January  6,  1916. 
MRS.  F. 
One  para;  menstruation  regular.     Weight   184  pounds. 
Last  menstruation  October  3,  1915. 
Had  aborted  previously. 

October  17,  1915,  was  the  first  opportunity  for  impreg- 
nation. 

Spotted  December  24th. 
Delivered  June  25,  1916. 


CASES  433 

1920.  Menstruation  regular;  last  menstruation  February 
4th,  but  less  than  usual;  says  she  "feels  life"  in  spite  of  her 
menstruation.  Stated  that  her  grandmother  did  not  know 
she  was  pregnant  with  one  of  her  children  because  she  men- 
struated for  3  months.  Weight  193  pounds.  Had  gained  in 
weight,  but  is  now  losing. 

Examination :    No  pregnancy. 

Blonde  fuzzy  hair  over  the  face,  but  no  change  in  the 
character  of  the  nose.  Has  excellent  color  and  is  flushed. 
Suggestive  of  post,  pituitary  activity. 

Insists  that  she  "feels  life."  Is  told  that  she  probably 
is  conscious  of  uterine  contractions  felt  in  exaggerated  form. 

Therapy :    Pituitary  extract ;  whole  lobe ;  grains  5  T.  I.  D. 

Februai-y  27th.  Has  the  same  sensation,  the  same  "feel- 
ing of  life." 

Therapy :    Placental  extract,  grains  5  T.  I.  D. 

March  8th.  Since  taking  placental  extract  has  lost  the 
sensation  which  she  describes  as  the  feeling  of  life.  States 
that  all  of  her  family  have  changed  life  late;  her  mother  at  the 
age  of  60. 

Diagnosis :  Post,  pituitary  overactivity,  causing  uterine 
contractions. 


March  17,  1920. 
MRS.  H.  F. 

Married  12  years;  0  para.  0  abort.  Operation  11  years 
ago  left  ovary  and  appendix  removed.  Round  ligament  oper- 
ation. 

Menstruation  began  at  16>4  years;  every  4  weeks,  1  day, 
scant.  Always  scant  even  before  operation. 

The  visible  thyroid,  considerably  enlarged,  attracted  at- 
tention. The  patient  replied  that  she  had  noticed  it  for  2 
years. 

Patient  has  had  scarlatina,  measles,  croup  (says  she  was 
always  croupy),  "malaria,"  "bronchitis  every  winter." 

Is  "nervous,  and  always  was  so";  is  afraid  to  be  alone; 
28 


434  THE    ENDOCRINES 

is  frightened  because  her  father  died  of  cancer,  and  so  the 
"stitches  in  her  heart"  make  her  pay  attention  to  her  left 
breast.  She  dreams  at  night  and  is  always  frightened  by 
them.  She  suffers  from  cardiac  palpitation  when  she  climbs 
the  stairs,  becomes  excited  or  is  frightened  and  is  afraid  that 
she  may  go  out  of  her  mind. 

She  flushes  readily.  She  has  a  sore  feeling  over  the  stom- 
ach and  under  the  left  breast.  She  complains  of  headaches. 
She  is  not  constipated,  stating  her  bowels  are  always  loose. 

Examination :  Pain  in  the  left  side  and  backache  due  to 
large  retroflexed  uterus  containing  a  fibroid.  A  pessary  which 
her  doctor  inserted  failed  to  replace  the  uterus.  Her  pulse  is 
slow  and  her  hands  are  blue  and  cold. 

The  daily  amount  of  urine  as  reported  is  normal. 

Her  headaches  are  in  the  back  of  her  head,  radiating  down 
the  neck  and  back  of  the  ears. 

Her  husband  states  that  for  a  year  she  had  been  taking 
"pituitary  extract  and  also  thyroid." 

Diagnosis  :  Adrenal  medulla  plus,  cortex  minus ;  glandu- 
lar ovary  plus,  with  probable  corpus  luteum.  Pituitary  an- 
terior is  minus  and  posterior  pituitary  is  plus. 

Therapy :  Pituitary  anterior,  ovarian  residue,  suprarenal 
extract,  placenta. 

June  9.  Above  extracts  given  in  varying  combinations 
have  caused  great  improvement,  but  patient  cannot  be  alone. 


March  19,  1920. 
MRS.  H. 

Married  12  years;  2  para,  second  5  years  ago;  nursed  for 
18  months  with  no  amenorrhea;  1  abort.  11  years  ago. 

Menstruation  regular,  4  days'  duration. 

Symptoms :     Pain  in  region  of  gall  bladder  and  pylorus, 
backache,  leucorrhea,  "falling  of  the  womb"  and  headaches. 

Examination  :    Descensus  uteri ;  fibrosis  uteri. 

Ideal  vaginal  operation,  1920. 

April  14,  1920.    Uterus  enlarged,  menorrhagia. 

Therapy :    Mammary  extract  and  thymus. 


CASES  435 

April  27,  1920.  Pain  in  the  right  hypochondrium  and 
headaches. 

May  12,  1920.  Pain  in  right  hypochondrium,  burning 
sensation  in  tongue. 

This  patient  has  prominent  bulging  eyes,  right  eye  more 
prominent  than  left.  Her  headaches  are  over  right  eye,  over 
the  scalp,  and  radiate  down  the  neck. 

Therapy :    Thyroid  and  placental  extract. 

May  19,  1920.  Patient  feels  trembly  in  the  hands  and  is 
more  nervous  than  usual.     Pressure  110,  pulse  92. 

Therapy:     Ov.  residue,  suprarenal,  placental. 

The  case  is  one  of  hyperthyroidism,  hyperadrenalism,  with 
posterior  pituitary  plus. 

]\Iay  26.    Head  feels  better.     Pressure  130,  pulse  84. 

The  pressure  rose  after  stopping  thyroid  and  adding  su- 
prarenal. 

Therapy:     Plac,  suprarenal,  pituitary  anterior. 

June  21.     Pressure  110,  pulse  88. 


MISS  R. 

Thirty-four  years-  of  age;  unmarried.  Complains  of 
goitre  which  she  says  interferes  with  her  breathing.  Both 
lobes  are  affected,  the  right  more  than  the  left ;  the  right  is 
enlarged  considerably  and  is  soft.  Though  complaining  of 
palpitation  at  times  and  of  sleeplessness,  her  pulse  on  examina- 
tion is  only  60. 

Therapy :     Placenta,  suprarenal,  ovarian  residue. 

May  26th.  Patient  feels  better,  sleeps  better ;  the  goiter  on 
the  left  side  is  smaller.     Pressure  140,  pulse  70. 

Therapy  :     Same  as  above. 

June  9th.     Pressure  150. 

Therapy:  Ovarian  residue  5  gr..  thyroid  extract  \I6  gr., 
placental  extract  3  gr. 

June  16,  1920.  Pressure  140.  Complains  of  headaches 
every  morning  and  of  a  nasal  catarrh  each  morning. 

Therapy:     Mammary,  thymus,  placenta. 

June  30th.     Better  in  every  way.     Goitre  smaller. 


436  THE    ENDOCRINES 

March  7,  1918. 
MRS.  K. 

Operated  on  for  ovarian  tumor,  size  of  a  3^  months' 
pregnancy. 

Seen  in  consultation  November  25,  1919,  for  toxemia  of 
pregnancy.  Albumin,  casts,  blood  pressure  180,  rapidly  fail- 
ing vision,  oedema  legs  and  arms.  No  fetal  heart  sounds 
heard. 

Castor  oil  administered;  prompt  response  preceded  by 
an  eclamptic  attack;  morphine  without  atropine  given  in  large 
doses. 

Delivery  of  dead  macerated  fetus.  Frequent  eclamptic 
attacks,  a  severe  one  following  spinal  puncture  for  the- asso- 
ciated profound  coma ;  high  colonic  sod.  bicarb,  irrigations ; 
morphine;  gradual  improvement.     Complete  recovery. 

March  8,  1920.  Last  menstruation  February  29,  pre- 
ceded by  heavy  throbbing  in  the  neck,  palpitation;  tremor  of 
the  hands.  Was  nervous  and  afraid ;  had  an  attack  of  influ- 
enza with  slight  pneumonia  1  year  ago. 

At  the  present  time  hands  and  feet  are  cold,  circulation 
is  poor;  has  menstruated  only  twice  since  her  eclamptic  at- 
tacks of  November  28th.  Mother  has  a  goitre  in  severe  form, 
and  patient  is  fearful  she  will  develop  the  same. 

Diagnosis :  Hypothyroidism  with  premenstrual  hyper- 
thyroidism.    Adrenal  involvement. 

Therapy :    Ovarian  extract,  plus  thyroid,  plus  suprarenal. 

Note  :  Will  change  prescription  a  week  before  menstrua- 
tion. 


May  21,  1919. 
H.  G. 

Married  27  years ;  1  para.  26  years  ago ;  1  abort.  23  years. 
Appendix  removed  4  years. 

Menstruation  regular,  2  days'  duration. 

Premenstrual  phenomena :  Duration  1  week ;  dizzy, 
breasts  full,  deoression. 


CASES  437 

Complaint :  Pain  in  the  right  side,  backache,  a  sense  of 
dropping  down,  troubled  with  dreams. 

Examination :     Small  fibroid  in  the  uterus. 

Therapy :     Mammary,  ergotin,  pyramidon. 

September  6,  1919.  Examination  shows  fibroid  polyp  of 
the  cervix  not  present  at  the  first  examination.  This  polyp 
was  apparently  extruded  by  the  above  medication. 

December  16,  1919.  The  fibroid  polyp  protruding  from 
the  cervix  has  caused  no  bleeding. 

February  9th.     Therapy :    Pyramidon  and  placenta, 

February  25th.  Patient  reports  that  the  medication  makes 
her  feel  tired. 

March  16th.  Continuation  of  the  same  medication  makes 
the  patient  tired  and  languid,  and  her  legs  feel  ''like  paralyzed." 

This  patient  is  one  among  the  many  of  the  several  hun- 
dred to  whom  placental  extract  was  administered  who  re- 
marked that  she  felt  tired  and  sleepy.  When  I  first  began 
the  administration  of  placental  extract,  one  of  the  principles 
guiding  its  administration  was  the  probability  that  it  was 
an  antagonist  to  the  posterior  pituitary.  Many  of  the  patients 
complained  of  a  peculiar  feeling  in  the  back  of  the  head,  of 
dizziness,  and  many  complained  of  palpitation.  If  the  pla- 
centa were  an  antagonist  to  the  posterior  pituitary,  and  if  the 
posterior  pituitary  is  concerned  with  the  cerebrospinal  fluid, 
and  if  pituitary  over  or  underactivity  increases  the  tension 
of  the  cerebrospinal  fluid,  then  the  occipital  headaches,  stiff- 
ness of  the  neck,  pain  between  the  shoulders,  and  pain  radiating 
down  the  legs  might  well  be  relieved  by  placental  extract. 
Placental  extract,  then,  in  all  probability,  by  affecting  osmosis 
in  the  membrane  of  Gley,  might  relieve  this  increased  tension. 
The  experience  noted  in  this  case  was  duplicated  so  many  times 
that  placental  extract  was  given  for  these  indications. 

March  10th.  The  patient  was  given  suprarenal  extract  and 
pituitary  anterior. 

March  18th.    Patient  reports  that  she  is  feeling  fine. 

Therapy:     Mammary,  thymus,  and  ovarian  residue. 

June  16th.    Has  been  feeling  well.    Is  awaiting  menstrua- 


438  THE    ENDOCRINES 

tion  in  three  days.  Her  legs  shake  a  few  days  before  men- 
struation and  she  can  scarcely  stand.  In  the  last  three  weeks 
the  last  phalanx  of  her  middle  finger  shows  the  typical  thick- 
ening so  frequently  noted  in  the  climacterium.  Blood  pres- 
sure 150,  pulse  72. 

Therapy :     Placenta  and  thyroid. 

June  16th:  Is  expecting  menstruation  in  3  days.  Be- 
fore menstruation  her  legs  are  always  shaky  and  she  finds  it 
impossible  to  stand.  The  patient  has  a  blood  pressure  of  150 
and  a  pulse  of  72.  She  has  been  taking  mammary  extract, 
thymus,  and  ovarian  residue. 

June  18th.  During  menstruation  developed  tachycardia 
140,  proof  of  the  underlying  hyperthyroidism. 

Therapy :     Placental  extract  plus  thyroid  1/6. 

June  18th.  The  patient  is  menstruating,  has  felt  weak, 
and  has  marked  palpitation.  Her  pulse  is  140.  This  patient 
has  been  taking  placental  extract,  which  made  her  feel  tired 
and  languid  and  her  legs  felt  as  if  paralyzed,  I  have  in  several 
instances  noted  the  development  of  palpitation  after  the  ad- 
ministration of  placental  extract,  which  fact  suggests  that  in 
many  cases  it  stimulates  thyroid.  At  this  time  thyroid,  gr. 
1/6,  was  added  to  placental  extract,  and  administered  shortly 
before  menstruation  to  determine  the  nature  of  the  premen- 
strual shakiness  and  weakness  of  the  legs.  It  accentuated  the 
annoyances  and  developed  a  tachycardia  of  the  rate  of  140, 
which  is  quite  sufiic-ient  to  call  attention  to  the  adrenal  medulla 
or  the  thyroid,  with  the  latter  as  the  most  probable  factor 
in  the  production  of  the  premenstrual  annoyances. 


January  7,  1915. 
MRS.  H.  J. 

Five  para,  last  11  years  ago.  Menstruation  irregular, 
every  6  weeks  to  2  or  3  months. 

Last  menstruation  November  2nd,  then  December  20th, 
now  bleeds  off  and  on  for  many  days! 

Operation  for  cystocele  and  rectocele. 


CASES  439 

October  26,  1918.  Gives  history  of  regular  menstruation, 
but  stains  for  a  week  afterwards. 

Therapy :    Thymus  plus  mammary,  plus  ergotin. 

August  1,  1919.    Excessive  bleeding  at  menstruation. 

Therapy:  Mammary  extract  and  pituitary  anterior  (not 
obtained  at  my  druggist's). 

Curetted  in  October,  1919,  since  which  time  she  has  taken 
mammary  extract  and  pituitary  anterior. 

February  22.  1920.  She  stopped  taking  the  capsules, 
and  the  next  day  after  an  amenorrhea  of  8  weeks  she  began 
to  bleed  and  has  spotted  ever  since  up  to  March  10,  1920. 

March  10,  1920.  Mammary,  plus  thymus,  plus  pituitary 
anterior  are  given. 

She  is  a  broad  shouldered,  thick  chested  patient  with 
pretty  face  and  high  color.  She  is  the  type  which,  as  I  have 
very  often  found  in  previous  years  in  doing  my  vaginal  pro- 
lapse operation,  has  large  ovaries  with  no  sign  of  atrophy. 
She  undoubtedly  has,  as  many  of  these  cases  have,  an  unusually 
active  post,  pituitary.  I  have  given  her  as  yet  no  placental 
extract  since  I  am  desirous  of  proving  if  there  is  value  to 
pituitary  anterior  as  an  antagonist  to  the  pituitary  post. 


February  23,  1920. 
MRS.  H. 

Married  13  years;  0  para;  3  aborts,  (self  induced). 

Operated  7  years  ago  for  rectal  itching,  hmds.  and  fistula, 
and  the  uterus  was  curetted. 

Menstruation  began  at  14  years,  every  5  weeks. 

In  the  last  7  years  has  gone  3  months  over  her  period  on 
several  occasions  without  being  pregnant. 

When  she  menstruates  she  stains  for  2  weeks  and  then 
flows  for  2  weeks. 

Premenstrual :  For  the  last  five  years,  1  week  before 
each  menstruation  she  feels  "like  crazy,  is  nervous,  tosses  at 
night  and  her  rectal  itching  is  worse." 

The  intervals  between  her  menstruations  vary  from  2  to 
6  weeks. 


440  THE    ENDOCRINES 

Examination :    Uterus  retroverted  and  enlarged. 

Has  had  frequent  cardiac  palpitation  for  the  past  year. 

Masturbated  when  5  years.  Continued  this  habit  and 
enjoyed  it  till  married. 

Intercourse  pleasurable  till  2  years  ago. 

Affectionate,  likes  children,  cries  easily. 

"Less  passionate  for  2  years,  and  has  gained  considerably 
in  weight." 

Diagnosis:  Thyroid  plus,  post,  pituitary  (unstable),  ac- 
tion diminished  in  the  last  2  years. 

Therapy :    Ovarian  extract,  plus  mammary,  plus  placental. 

The  following  letter  was  sent  to  the  physician  of  this 
patient  referred  to  me  for  diagnosis : 

Mrs.  H..  Fairly  tall,  broad-shouldered,  thick-chested, 
hair  on  the  forearms,  slight  mustache,  slight  beard,  broad 
nose,  (but  little  hands). 

This  means  good  anterior  pituitary,  but  no  action  on 
hands  and  feet.     Is  sensible  and  a  good  business  woman. 

Masturbated  and  enjoyed  it  till  marriage.  Was  passionate 
until  two  years  ago,  since  which  time  there  is  less  inclination 
and  she  has  gained  in  weight.  Is  anxious  to  become  pregnant. 
Menstruation,  while  irregular,  the  interval  sometimes  being 
as  long  as  six  weeks,  consists  of  spotting  for  two  weeks  and 
then  a  profuse  bleeding  for  two  weeks. 

She  has  been  manifestly  stimulated  all  her  life  by  the  sex 
elements  of  the  pituitary,  adrenal  cortex  and  ovary.  Asso- 
ciated with  this  has  been  unusual  activity  of  the  anterior  pitui- 
tary. She  has  been  hyperthyroid  at  times,  suffering  for  one 
year  with  palpitation. 

In  her  own  words,  she  feels  for  the  past  seven  years  for 
a  week  before  each  menstruation  ''like  crazy,"  she  is  nervous, 
tosses  at  night  and  her  rectal  itching  is  worse.  A  hyperthy- 
roidism and  hyperpituitarism  is  in  play  during  the  premen- 
strual period. 

Her  ovarian  function  is  partly  inhibited  by  her  anterior 
pituitary  and  therefore  she  has  at  various  times  gone  from  six 
weeks  to  three  months  between  her  menstrual  periods. 


CASES  441 

This  patient  needs  ovarian  extract  to  make  her  regular, 
mammary  ext.  to  diminish  the  amount  of  bleeding  and  placental 
ext.  to  still  further  inhibit  the  posterior  lobe. 


April  26,  1920. 
MRS.  H. 

Menopause  4  years  ago;  1  slight  menstruation  7  months 
ago. 

Complaint :  Gain  in  weight,  pain  in  the  left  shoulder, 
numbness  of  the  left  arm,  is  nervous,  wakes  up  at  night  and 
can't  fall  asleep  again,  and  feels  frightened. 

Has  cardiac  palpitations.  Her  flushes  are  not  as  severe 
as  they  were.  Patient  observes  that  as  her  flushes  diminished 
her  neuritis  began. 

Pulse:     Erect  position  120,  reclining  100. 

Blood  pressure  180. 

Therapy:    Placenta,  ov.  residue. 

May  5,  1920.  Sleeps  better,  is  more  quiet,  has  less  palpi- 
tation. 

Pulse  90,  blood  pressure  160.  Skin  feels  smoother  and 
more  moist  as  if  she  had  taken  thyroid. 

May  15,  1920.  Feels  better  in  every  way.  Blood  pres- 
sure 140. 

Therapy :    Placental,  ov.  residue,  suprarenal  ext. 

May  28.    Pressure  150  (possibly  due  to  suprarenal). 

Therapy :     Placenta  gr.  iii,  thyroid  g  1/6. 

June  23.     Placenta. 

June  24.    Sleeps  well,  feels  well,  flushes  gone. 


October  8,  1915. 
MRS.  M.  L. 
Married  14  years ;  2  para,  0  abort. 

Menstruation  regular,  but  for  the  last  4  years  persists 
for  10  days.    Loses  large  clots  with  pain. 

Complaint :    Menorrhagia,  pain  in  the  left  side,  backache, 
bladder  pressure  and  nervousness. 


442  THE    ENDOCRINES 

Examination:  Uterus  enlarged  and  retroverted.  Large 
rectocele. 

October  15,  1915.    Duhrssen  oper.  and  perineorraphy. 

May  25,  1919.  Menstruation  Q.  3  weeks,  large  in 
amount.     Indigestion. 

Therapy.  Ergotin,  menthol,  sodium  bicarb,  with  very- 
small  doses  of  veronal. 

March  23,   1920.     Last  menstruation  November,   1919. 

Complains  of  flushes,  pain  in  the  right  arm.  Her  neck 
and  back  are  stiff.  She  feels  worn  out,  her  hands  feels  numb 
and  cold  in  the  mornings.  She  voids  little  and  occasionally 
vomits  when  the  pain  in  her  neck  and  back  become  worse. 
Blood  pressure  200. 

Therapy:  Ovarian  extract,  plus  suprarenal,  plus  pla- 
cental. 

June  1,  1920.  Last  menstruation  occurs  in  November, 
but  at  the  end  of  April  she  spotted  and  stained  for  3  weeks. 
The  prescription  given  on  March  23rd  was  taken  for  only 
1  week  as  the  patient  went  away  on  a  pleasure  trip.  Her 
flushes  are  not  severe,  her  headaches  are  somewhat  better. 
She  wakes  early  and  cannot  fall  asleep.  She  cannot  do  much. 
She  is  tired,  "belches  for  hours"  and  cries  all  the  time.  Her 
right  arm  is  painful  and  her  fingertips  tingle  continuously. 

Pelvic  examination:    Normal,  blood  pressure  190. 

Therapy:  Placental  extract,  plus  thyroid,  plus  ovarian 
residue. 

This  is  another  illustration  of  the  varied  phenomena  oc- 
curring at  the  menopause  period.  The  patient  is  broad 
shouldered,  thick  chested.  She  has  light,  fuzzy  hair  on  the 
cheeks  and  chin,  which  I  consider  as  due  to  the  anterior  hypo- 
thysis  in  contradiction  to  the  thicker  growth,  which  I  refer  to 
the  suprarenal  cortex.  The  high  blood  pressure  is  an  evidence 
of  the  overactivity  of  the  posterior  pituitary  associated  with 
thyroid  minus.  Hence,  the  pain  and  stiffness  in  the  neck  and 
along  the  spine.  The  gastric  annoyances  are  probably  to  be 
referred  to  the  same  etiology.  The  same  cause  serves  readily 
to  explain  the  physical  and  the  mental  asthenia. 


CASES  443 

March  6,  1919. 
MRS.  H. 

Married  27  years;  3  para,  last  18  years  ago;  abort.  3 
years  ago. 

Menstruation  every  2  weeks  with  pain  for  the  last  5 
months. 

Complaint :     Menorrhagia  and  headaches. 

Examination :  Large  fibroid  consisting  of  several  tumors, 
one  large  immediately  underneath  the  bladder. 

Blood  pressure  180. 

March  12,  1919.  Abdominal  hysterectomy  with  retention 
of  ovaries.     (?)     Appendix,  as  in  all  laparotomies,  removed. 

April  17,  1919.  Ovarian  extract,  plus  thyroid,  plus  supra- 
renal, as  a  tonic  and  to  remove  the  slight  flushes. 

Therapy :  Continued  intermittently  in  May  and  June. 
Suprarenal  being  given  with  ovarian  extract  in  capsule  form. 

December  16,  1919.     Flushes  more  marked. 

Therapy :    Ovarian  extract  tablets  only. 

March  12,  1920.  Patient  comes  and  wants  prescription 
for  the  capsules  as  they  ''worked  better  than  the  tablets." 

Therapy:  Ovarian  extract,  plus  suprarenal  extract,  plus 
placental. 

Note  :  The  suprarenal  extract  is  given  because  of  the 
cortex.  The  placenta  is  given  to  overcome  the  action  of  the 
post,  pituitary. 


March  19,  1919. 
MRS.  F. 

Married  46  years;  7  para.,  the  last  30  years  ago;  2  aborts. 

Hysterectomy  2  years  ago  for  prolapse  of  the  uterus  as- 
sociated with  menorrhagia  occurring  every  3  weeks. 

Complaint :     Flushes,  indigestion,  nervousness. 

At  that  time  the  symptoms  were  viewed  as  a  relative 
Graves'  disease  after  hysterectomy,  the  type  so  often  ob- 
served in  the  normal  climacterium. 

Therapy :    Corpus  luteum. 

June  1,  1920.     Patient  complained  of  flushing,  marked 


444  THE    ENDOCRINES 

occipital  headaches,  pains  in  the  feet,  hands,  and  in  innumer- 
able areas  of  the  body.  Blood  pressure  210.  Red  line  on 
scratching  the  skin  was  immediate  and  marked. 

Therapy :    Thyroid  and  placenta. 

June  16th.     Pressure  210. 

Therapy :    Mammary,  thymus,  placenta,  thyroid. 

June  30th.     Pressure  170. 


May  26,  1920. 
MRS.  A. 

Married  21  years;  2  para,  the  second  14  years  ago.  No 
open,  0  abort. 

Menstruation  is  regular,  6  to  8  days,  large  in  amount, 
losing  large  clots  for  the  past  1  ^  years. 

Premenstrual  phenomenon,  none. 

Complaint :     Menorrhagia. 

The  patient  has  a  marked  exophthalmos.  Flushes  easily, 
and  her  neck  becomes  readily  scarlet.  No  goitre.  Blood  pres- 
sure 155,  pulse  110. 

Her  sister,  who  has  long  been  a  patient  of  mine,  suffers 
from  hypothyroidism  which,  when  first  seen  many  years  ago, 
was  practically  a  myxoedema.  A  brother  had  Graves  disease 
and  died  later  of  pernicious  anemia. 

June  2.     Pressure  140,  pulse  104. 

The  blood  pressure  makes  the  overactivity  of  the  adrenal 
medulla  more  probable  than  any  hyperthyroidism.  This  patient 
has  no  enlarged  thyroid,  in  fact  it  seems  atrophic. 

Cases  like  this  one  with  exophthalmos,  tachycardia  and 
high  blood  pressure  tend  to  rule  out  of  consideration  the  role 
of  overactivity  of  the  thyroid  in  many  cases  of  enlarged  thy- 
roid. In  other  words,  enlargement  of  the  thyroid  does  not 
necessarily  prove  it  to  be  overacting  even  if  symptoms  of 
Graves  diseases  be  present. 

Diagnosis :  Pituitary  posterior  plus,  adrenal  medulla 
plus. 

Examination :    Fibroid  of  uterus,  larger  than  a  male  fist. 

Therapy :    Mammary  extract,  plus  thymus,  plus  placental. 

July.     Tumors  practically  gone. 


CASES  445 

October  10,  1919. 
MRS.  Z. 

Married  28  years ;  multi  para.  Menstruation  now  occurs 
every  2  weeks,  associated  with  pronounced  headaches.  The 
menorrhagia  and  headaches  date  back  3  years. 

Examination  :  Enlarged,  descended  uterus,  marked  cysto- 
cele  and  rectocele. 

Vaginal  hysterectomy  November,  1919;  ovaries  retained. 

May  27th.  The  patient  complains  of  no  flushes  as  yet. 
(The  ovaries  were  retained  at  operation.)  She  suffers  from 
periodical  headaches,  occurring  at  intervals  representing  the 
menstrual  cycle.     Blood  pressure  160.     Urine  normal. 

Therapy  :     Placental  extract  and  thyroid. 

In  those  cases  in  which  the  ovaries  are  retained,  in  the 
operation  of  hysterectomy,  a  fair  proportion  develop  flushes 
after  a  period  of  several  months  or  years.  Some  experience 
the  flushes  within  a  short  time  after  operation.  I  consider 
the  flushes,  the  headache  and  the  high  blood  pressure  in  many 
of  these  cases  an  evidence  of  overactivity  of  the  posterior 
pituitary.  The  development  of  glycosuria  is  in  many  cases  to 
be  referred,  at  least  partly,  to  the  same  cause. 

June  31.     Headaches  better.     Pressure  140,  pulse   100. 

Therapy:  Plac,  thyroid,  suprarenal.  The  latter  is  added 
because  of  the  rapid  pulse. 


May  18,  1920. 
MISS  B. 
Patient  49  years  of  age  and  unmarried. 
The  history  of  her  first  visit  (May  15,  1919)  copied  from 
list  she  handed  me,  reads  as  follows : 

Eye  trouble,  hardening  of  retina,  bloodshot. 

Ner\'ousness,  neuritis,  headache. 

Rheumatism,  arthritis  and  gout. 

High  blood  pressure,  160  or  more. 

Hemorrhoids,  dizziness. 

Poor  circulation,  cold  feet  and  hot  head. 

Constipation,  weakness  in  standing. 


446  THE    ENDOCRINES 

Dry  skin,  brittle  nails,  dry  hair,  sore  throat,  mouth,  eyes 
and  nose. 

May  15,  1919.  Her  blood  pressure  was  180.  She  was 
given  bromides  and  glonoin  and  continued  under  care  of  the 
opthalmologist. 

Next  visit  May  6,  1920.  Complains  in  addition  of  head- 
aches and  pain  in  the  fingers  and  toes.  Was  bitten  by  cat  a 
year  ago  and  thinks  that  is  why  all  symptoms  are  worse,  es- 
pecially at  night. 

Blood  pressure  220. 

Therapy :     Placental,  thyroid. 

May  14.    Pressure  160. 

Therapy :    Placenta  g  iii,  thyroid  g  1/6. 

May  28.    Pressure.  160.. 

Therapy :  Placenta,  thyroid. 


May  27,  1920. 
MRS.  M. 

Married  31  years,  2  para,  1  artificial  abort,  because  of 
nephritis. 

Menstruation  began  at  13  years. 

Always  suffered  from  dysmenorrhea  up  to  year  ago,  when 
the  menopause  was  established  after  a  gradually  progressive 
amenorrhea. 

Complaint :  Flushes  and  headaches  which  are  occipital, 
radiating  dow  nthe  neck.  Has  pains  of  this  sort  and  likewise 
"In  the  face"  for  5  years.  Notices  that  her  headaches  and 
flushes  seem  to  come  at  the  same  time. 

Sleeps  well  but  often  wakes  up  with  headaches. 

Urinates  often,  but  not  a  large  amount.  Was  operated 
on  3  years  ago  for  hemorrhoids.  She  nursed  her  children  for 
9  months,  having,  as  she  said,  "enough  milk  for  2  babies."  She 
has  suffered  for  years  with  marked  hyperacidity  and  has  been 
on  a  selected  diet. 

Therapy :    Ovarian  extract  plus  placental. 

May  10,  1920.  Flushes  have  disappeared  but  above  pre- 
scription made  her  "heart  burn"  worse.     Blood  pressure  110. 


CASES  447 


Therapy:    Placental,  ov.  residue. 
Headaches  and  flushes  markedly  better. 


April  28,  1920. 
MRS.  R.  W. 
Age  69. 

Hysterectomy  4  yeai-s  ago  for  total  prolapse. 
Complains  of  a  dizzy  spell  3  weeks  ago  and  notices  for 
the  last  '3  weeks  that  her  vision  is  becoming  poorer. 
Blood  pressure  190. 
Therapy:     Placenta,  thyroid. 

May  12,  1920.     Blood  pressure  170,  therapy  continued. 
May  22.     Pressure  170. 

Therapy :     Thyroid,  mammary,  .thymus,  placenta. 
June  1.    Pressure  150,  pulse  88. 
Therapy :    Same. 
June  23.     Pressure  140.     Feels  perfectly  well. 


May  17,  1920. 
MRS.  W. 

Married  15  years,  3  para,  last  4  years  ago. 

Op.  3^  years  ago  for  displacement  of  uterus. 

Menstruation  has  always  been  regular,  3  days'  duration. 

In  1919,  amenorrhea  once  of  3  months'  duration. 

Last  menstruation  December,  1919. 

Premenstrual  phenomena :  Headaches,  nervousness  and 
irritability. 

Sleeps  well,  has  no  dreams. 

Tired ;  talking  tires  her  mentally ;  social  affairs  which  she 
formerly  enjoyed  are  now  a  burden.  Suffers  from  indigestion, 
gas  and  constipation.  Has  been  told  her  stomach  "has  fallen" 
and  wears  a  special  but  very  uncomfortable  abdominal  support. 

Had  all  infectious  diseases  of  childhood,  including  scarla- 
tina, diphtheria  and  mumps. 

For  years  has  had  frontal  sinus  trouble  and  antrum 
trouble. 

Her   headaches    which   occurred   with   menstruation   are 


448  THE    ENDOCRINES 

better  for  the  last  6  months.  (Period  of  present  amenorrhea 
is  5  months.) 

As  a  young  girl,  was  altruistic,  and  helped  the  "people  in 
the  poor  house"  of  her  town. 

The  husband  of  an  aunt  became  insane,  and  no  one  could 
manage  him  but  this  patient  herself.  Was  religious  and 
thought  she  ought  to  do  something  worth  while;  became  a 
nurse,  but  "hated  to  take  money  for  services," 

Though  well  to  do,  she  started  a  sanitarium  in  the  coun- 
try for  the  care  of  the  mentally  affected,  in  which  she  takes 
interest  for  purely  altruistic  motives. 

Pelvic  examination :  Uterus  slightly  larger  than  normal, 
both  ovaries  atrophic. 

Patient  is  of  slight  build,  with  no  adipose  tissue,  is  thin, 
has  no  hair  on  the  arms  or  legs,  has  some  slight  varicosities, 
some  dilated  veins  on  the  lower  extremities. 

She  was  formerly  very  thirsty  and  passed  much  urine,  but 
was  advised  to  drink  less  water,  and  is  not  annoyed  so  fre- 
quently. 

Pulse  72,  pressure  125. 

Diagnosis :     Physical  and  mental  asthenia. 

Therapy :     Ovarian,  thyroid,  suprarenal. 

May  24.  Pressure  110.  More  nervous.  Indigestion 
better. 

Therapy :     Placenta,  suprarenal,  pituitary  post. 

June  2.    Less  nervous,  stronger.    Never  felt  so  well. 

Therapy:    Same. 


May  19   1920, 
MRS.  K. 
Married  6  years ;  no  para. 

March  12,  1918,  had  a  miscarriage  at  63>2  months;  3 
years  ago  she  had  a  curettage.  Her  menstruation  occurs  every 
4  weeks  to  5  weeks.  Patient  states  that  5  weeks  after  her  mis- 
carriage or  premature  labor  it  was  discovered  that  her  kidneys 
were  affected  and  she  was  confined  to  bed  for  three  weeks. 
Subsequently   her    physician    gave   her    twenty    hypodermics, 


CASES  449 

which  she  states  were  corpus  luteum,  after  which  she  began  to 
suffer  from  headaches  and  excessive  nervousness.  One  week 
before  each  menstruation  she  has  a  pecuHar  feeHng  in  the  head, 
which  she  describes  as  a  "dropping  in  the  head  hke  a  bunch  of 
pennies  shaken  in  the  hand."  She  wishes  to  become  pregnant, 
but  has  taken  precautions  up  to  3  months  ago.  She  is  nervous, 
fearful,  has  fluhses  in  the  face,  terrible  headaches  at  men- 
struation, and  hopes  she  won't  become  "crazy."  She  has 
dreams  which  frighten  her  terribly,  and  they  deal  with  death, 
murder  and  fires.  At  one  time  her  dreams  w^ere  so .  terrible 
that  she  was  afraid  to  go  to  sleep. 

Complaint :  Pain  in  the  right  side ;  headaches  on  the  top 
of  her  head  and  dow^n  her  neck,  usually  occurring  a  week  be- 
fore and  a  week  after  menstruation. 

Examination :  Pelvic  organs  normal.  Blood  pressure 
135 ;  pulse  70. 

Therapy :  Placental  extract,  grs.  3 ;  thyroid  extract,  gr. 
1/6. 

June  4th.     Blood  pressure  115,  pulse  72. 

June  11th.  Condition  the  same;  note  some  flushes  in  the 
face. 

Therapy :  Pituitary  anterior,  gr.  ^  ;  suprarenal  extract, 
grs.  2;  ovarian  extract,  grs.  5. 

June  12th.  Patient  feels  better,  is  less  fearful,  and  more 
confident.     Blood  pressure  118. 

Therapy :     Same  as  above. 


MRS.  E.  K. 

Married  the  first  time  11  years  ago.  Had  her  only  child 
10  months  after  marriage.  Nursed  for  9  months  and  did  not 
menstruate.  Her  husband  died  a  sudden  death  and  the  next 
day  her  milk  stopped,  her  menstruation  came  on.  she  had 
diarrhoea  for  several  days  and  cardiac  palpitation  which  per- 
sisted for  months.  Has  it  now  except  wdien  she  rests  fre- 
quently. 

She  married  a  second  time,  but  separated  soon  because  of 
incompatability.      No   abort.,    no   op.      Menstruates    every   4 


450  THE    ENDOCRINES 

weeks  for  only  2  days,  and  very  little.  Ex.  shows  the  uterus 
to  be  small  and  retroverted  and  was  told  by  a  phys.  that  her 
retroversion  was  the  responsible  factor. 

Her  premenst.  phen.  show  her  to  be  for  a  week  before 
menstruation  nervous,  very  sensitive,  and  she  cries  easily. 

Her  blood  pressure  is  120,  pulse  slow,  perspires  readily, 
has  good  color  and  a  smooth  skin. 

She  is  a  singer  in  a  church  choir,  has  a  good  voice,  could 
readily  obtain  engagements  at  concerts  and  recitals,  but  un- 
less she  rests  the  day  before  she  lacks  the  energy  to  do  her 
work,  and  unless  she  rests  the  day  after  she  is  "all  in." 

When  a  young  girl  her  mother  called  her  lazy.  And  she 
remembers  having  "no  pep,"  but  always  looked  well.  She 
was  a  good  student,  stood  among  the  highest  in  her  class  and 
entered  normal  college  at  16.  She  wet  her  bed  as  a  child, 
was  scolded  for  it  by  her  mother  and  now,  as  always,  urinates 
frequently.  In  this  connection  she  mentioned  her  boy  of  11 
years,  very  bright,  full  of  pep,  a  leader  among  the  boys,  a 
great  reader  of  books  and  the  soundest  sleeper  she  ever  knew, 
but  he  still  wets  the  bed. 

As  a  child  she  remembers  having  measles  and  when  5 
years  old  had  what  she  calls  pneumonia  and  was  unconscious 
for  16  days.  Has  had  frequent  colds  and  attacks  of  grip  and 
influenza. 

Volunteered  the  statement  that  she  wishes  to  get  well  for 
3  reasons.  They  are  as  she  stated,  first,  because  of  her  boy 
and  his  future,  and  her  desire  to  do  her  duty  to  him  which 
is  her  greatest  pleasure.  Second,  she  is  engaged  to  a  phy- 
sician now  studying  abroad,  who  wishes  to  marry  her,  but 
she  feels  that  she  is  not  well  enough.  Third,  for  the  sake  of 
her  career,  since  her  voice  is  really  a  good  one. 

When  asked  what  interferes  with  her  career,  she  an- 
swered, "I  am  so  tired,  I  haven't  the  strength,  I  cannot  get 
enough  sleep."  Then  she  said,  when  asked  if  she  was  blue 
or  depressed,  "No;  but  how  is  it  that  I  am  cheerful  in  spite 
of  it  all?" 


CASES  451 

Further  questioning  showed  that  she  and  her  mother  were 
incompatible ;  their  ideas  had  always  been  different ;  the  mother 
was  even  now  finding  fault  with  the  way  she  was  bringing  up 
her  boy.    Had  advised  her  to  send  him  away  to  school. 

Her  maternal  instinct  is  strong ;  she  is  affectionate  but  the 
sex  instinct  plays  no  part  in  her  life. 

The  action  of  the  hypophysis,  thyroid,  suprarenal  and 
ovary  was  explained  to  her ;  how  she  had  developed  into  a 
tall,  broad-shouldered,  healthy  appearing  woman ;  that  she 
had  inherited  a  fondness  for  study  and  a  bright  mind.  That 
these  glands  were  vulnerable  as  could  be  seen  from  her  amenor- 
rhoea  during  lactation ;  that  they  were  now  underacting  on 
her  physical  side;  that  her  lack  of  strength  and  desire  for 
sleep  were  the  physical  expression  of  this  lack  as  had  been  the 
case  during  her  earlier  years ;  that  their  action  on  her  mental- 
ity had  been  normal  since  she  had  been  a  good  student,  stood 
well  in  her  class,  was  interested  in  the  education  of  her  boy, 
and  had  ambitions  for  her  future.  That  they  had  acted  nor- 
mally in  conjunction  with  her  inherited  instincts  and  emo- 
tions; that  her  whole  life  and  her  unfortunate  marital  experi- 
ence had  still  left  her  with  a  pleasant,  open  mind,  susceptible 
to  encouragement,  and  that  the  understanding  of  her  condi- 
tion would  show  her  that  her  lack  of  energy  and  of  physical 
power  to  do  were  not  lack  of  control  of  mind  over  matter  or 
her  body,  but  lack  of  stimulation  of  certain  body  functions 
through  instability  of  certain  endocrine  elements.  That  though 
she  had  courage  she  lacked  physical  strength.  That  her  thyroid 
was  unstable,  overacting  at  times  or  in  certain  phases  as  was 
shown  by  her  diarrhoea,  her  palpitation,  etc.,  and  that  this,  with 
adrenal  medulla  overaction,  could  make  her  feel  tired  just  aa 
well  as  an  underaction  could  fail  to  furnish  energy. 

Was  given  ov.  extract  plus  suprarenal.  Thyroid  was-, 
given  to  test  her  hyperthyroidism  which  has  probably  been  the 
basic  factor  throughout  her  life. 

Thyroid  proved  her  to  be  hyperthyroid. 

Improvement  resulted  from  suprarenal  extract  and  hypo- 
dermics of  adrenal  cortex. 


452  THE    ENDOCRINES 

December  3,  1919. 
MRS.  S. 

Married  7  months;  no  precautions;  menstruation  regu- 
lar, duration  1  week. 

Complaint :    Pain  on  the  left  side,  worse  at  menstruation. 

Examination :    Retroversion,  cystic  left  ovary. 

Therapy :     Ovarian  extract  and  thyroid. 

March  18,  1920.  Has  taken  the  prescription  for  3 
months;  is  not  pregnant;  partner  has  not  been  examined.  Has 
a  suggestion  of  moustache,  and  hair  in  sciatic  region.  Is 
"afraid"  and  nervous  and  "imagines  lots  of  things."  Is 
this  way  only  since  marriage,  since  when  she  has  lost  40 
pounds.  Sleeps  poorly,  dreams  every  night  of  horrid  things, 
wakes  up  and  "shakes."  Dreams  of  dark  things  and  dark 
people.  As  a  child  was  always  afraid  of  the  dark;  would  not 
walk  into  a  room  alone.  Is  frigid,  but  just  before  and  during 
menstruation  has  libido.  Has  a  poor  appetite  and  frontal 
headaches.     Passes  little  urine. 

Looks  like  too  much  pituitary  post.,  and  too  little  anterior 
and  suprarenal  cortex. 

Therapy:  Placental  extract,  plus  residue,  plus  supra- 
renal. 


MISS  C. 
My  Dear  Dr.  S.  : 

I  saw  Miss  C.  My  diagnosis  of  her  case  is  one  of  hyper- 
pituitarism, posterior  lobe,  and  I  will  tell  you  why  I  think  so, 
because  some  day  I  wish  to  talk  this  and  other  cases  over  with 
you.  She  has  none  of  the  signs  of  an  overactive  anterior  hy- 
pophysis nor  of  an  overactive  adrenal.  She  is  distinctly  hyper- 
thyroid  or  hyperpituitary  or  both.  She  menstruates  regularly, 
has  an  elongated  uterus,  menstruates  for  three  days,  but  stains 
off  and  on  for  a  week.  While  not  suffering  from  dysmenorrhea 
she  has  had  three  attacks  of  pain  during  menstruation. 

Her  premenstrual  phenomena  are  swelling  of  the  breasts, 
she  becomes  excitable,  cries  three  or  four  days  before  each 
menstruation  and  describes  these  symptoms  as  "emotional."  She 


CASES  453 

was  called  hysterical  as  a  girl.  Each  year  she  entered  school 
and  did  her  work  with  enthusiasm  and  energy,  but  toward  the 
end  of  each  school  year  would  have  to  be  taken  out  and  given 
some  sort  of  a  rest  or  relaxation  because  she  worked  so  hard. 
She  is  engaged  to  be  married.  At  the  present  time  sees  her 
fiance  every  week  and  describes  her  instincts  and  emotions  by 
the  word  passionate.  She  knows  enough  about  the  theory  of 
Freud  to  be  moved  by  the  fear  that  these  reactions  are  immoral 
and  not  normal. 

Now,  I  believe  that  a  girl  who  is  hyperthyroid,  and  es- 
pecially one  who  is  hyperpituitary,  with  a  consequent  stimula- 
tion by  the  latter,  exerted  trophically  on  the  uterus  and  the 
sex  sphere,  has  its  parallel  in  the  stimulation  of  the  cerebral 
activities,  phantasies  and  thoughts  of  a  sex  quality.  I  do  not 
believe  that  it  is  necessary  for  one  factor  to  be  responsible 
for  the  other,  but  that  both  appear  more  prominently  in  the 
individual  whose  posterior  pituitary  is  active.  It  is  these  fac- 
tors plus  the  absence  of  many  of  the  physical  phenomena  of 
hyperthyroidism  that  have  led  me  to  make  the  distinction  be- 
tween the  excitability  of  hyperthyroidism,  and  its  flow  of 
language  and  thought,  and  the  cases  of  hyperpituitarism. 
So  far  as  I  can  judge,  the  above  explanation  is  much  more  satis- 
fying and  adds  much  more  to  the  respect  with  which  a  patient 
views  herself  when  such  an  explanation  as  I  have  given  is 
made  that  when  the  theory  of  Freud  is  invoked.  In  other 
words,  this  girl  has  had  a  sex  urge,  of  course  accentuated  by 
her  love  affair  and  by  her  engagement,  because  she  has  an 
overstimulating  posterior  pituitary ;  and  the  so-called  hysterical 
manifestations  recall  the  origin  of  the  word  hysteria  taken 
from  the  Greek  word  meaning  uterus  which  shows  that  the 
old  Greeks  realized  as  well  as  we  do  now  that  in  hysteria  there 
is  an  impulse  of  sex  which  they  traced  back  to  the  uterus,  but 
which  we  may  some  day  trace  back  to  a  gland  located  in  the 
brain  which  acts  trophically  and  in  a  stimulating  manner  on 
the  uterus;  but  which  by  the  very  fact  of  its  location,  in  the 
brain,  should  of  necessity  be  associated  in  a  trophic  manner 


454  THE   ENDOCRINES 

with  cerebral  activity  and  the  sex  side  of  our  mentality  and 
consciousness. 

I  explained  to  Miss  C,  this  physical  side  of  her  condition 
and  it  certainly  gave  her  great  relief  as  you  may  well  under- 
stand. Now  whether  this  idea  be  correct  or  no.  I  wish  you 
would  give  it  some  thought  and  give  me  the  benefit  of  your 
opinion. 

With  very  kindest  regards, 

Yours  very  sincerely, 

S.  W.  Bandler. 

January  29,  1920. 


MRS.  B. 

Forty-eight  years  old.  Married  30  years;  5  para.,  the 
last  17  years  ago;  no  operation. 

Menstruation  regular,  4  to  5  days,  large  in  amount  for 
the  last  few  years. 

Complaint:  Pain  in  the  left  side,  a  sense  of  dropping 
down.    Urinates  very  often. 

As  I  first  saw  the  patient  she  looked  tired,  quiet,  de- 
pressed, heavy  eyed,  and  cerebrally  myxoedematous. 

She  has  headaches  in  the  back  of  her  head,  radiating  down 
the  neck  and  behind  the  ears.  She  flushes  readily  and  red 
spots  appear  on  the  nose  and  face.  She  does  not  sleep  well, 
since  she  wakes  up  early.  When  she  wakes  up  she  feels  blue 
and  this  has  continued  for  two  years.  She  feels  worried,  but 
is  not  frightened. 

Examination:  Cystocele,  rectocele,  descensus  uteri. 
Blood  pressure  160. 

Diagnosis :     Post,  pituitary  plus,  thyroid  minus. 

Therapy:  Ovarian  extract,  plus  thyroid,  plus  placental 
extract. 


October  16,  1915. 
MRS.  Sp. 
Married  3  months.     Menstruation  regular.     Last  men- 
struation June  21,  1915.    Married  June  22,  1915. 


CASES  455 

Diagnosis :    Pregnancy. 

Delivery :     Normal, 

Some  time  subsequently  the  patient  became  pregnant 
again.  She  came  to  me  and  said  she  thought  it  was  too  soon 
after  her  first  delivery.  I  advised  her  strongly  against  any 
interference.  She,  however,  found  a  receptive  mind  in  the 
person  of  a  physician  who  told  her  that  she  was  not  pregnant 
but  that  she  needed  a  cervical  operation.  She  came  to  me  on 
May  21,  1917,  no  longer  pregnant,  feeHng  weak  and  tired, 
blood  pressure  120,  pulse  slow. 

Therapy:  Pituitary  extract  whole  gland,  plus  thyroid, 
plus  Blaud's  mass,  plus  arsenious  acid,  and  in  three  weeks  she 
came  and  said  she  felt  wonderful  and  looked  it. 

In  1918  she  menstruated  on  January  5th  for  the  last 
time  and  when  she  came  to  me  she  was  pregnant.  She  visited 
me  every  two  weeks  and  was  one  of  the  quietest  patients  I  have 
ever  had.  She  would  come  into  the  office,  nod  to  the  nurse 
and  to  me,  be  examined,  take  advice,  and  leave  without  a  word. 
Her  demeanor,  which  was  not  one  of  depression,  was  a  sub- 
ject of  remark.  The  morning  of  her  expected  date  she  tele- 
phoned that  she  was  having  pains,  ordered  a  taxicab  to  go  to 
the  hospital  and  I  awaited  word  of  her  arrival.  An  hour  and 
a  half  afterwards  I  was  called  suddenly  to  the  house,  found 
her  in  bed  with  her  coat,  shoes  and  clothes  on,  and  the  baby 
already  born.  Her  husband  had  been  unable  to  get  a  taxi  and 
she  had  this  precipitate  labor.  This  is  quite  enough  to  make 
the  diagnosis  of  post,  pituitary  hyperactivity. 

She  was  not  excited,  did  not  seem  to  be  frightened,  but 
was  decidedly  apathetic. 

Within  the  next  few  days  she  began  to  complain  about 
the  nurse,  refused  to  take  food  from  her,  insisted  upon  having 
the  baby  in  her  sight  all  the  time,  would  take  no  food  but  that 
prepared  by  her  mother,  told  me  of  all  the  plotting  there  was 
against  her  life,  even  became  suspicious  of  me,  became  violent 
and  developed  what  we  have  called  "a  post  partum  mania." 
A  psychiatrist  was  called  in  consultation  and  she  was  removed 
to  a  sanatorium. 


456  THE    ENDOCRINES 

March  19,  1920.  This  is  the  first  time  I  have  seen  the 
patient  since  she  went  to  the  sanatorium,  though  she  has  been 
home  several  weel<s.  She  states  that  she  has  menstruated  for 
2  weeks.  Her  eyes  are  somewhat  prominent,  but  were  always 
so.  She  has  now  no  premenstrual  phenomena.  She  flushes 
easily,  is  easily  frightened  and  states  that  dreams  frighten  her. 

Examination :  Her  uterus  is  normal ;  her  left  ovary  is 
markedly  cystic  with  irregular  nodules  distinctly  felt. 

She  volunteered,  of  her  own  accord,  the  following  state- 
ments about  the  sanatorium:  She  said  she  had  a  bad  time 
while  there,  that  they  put  her  in  a  straight- jacket  every  night, 
and  that  she  cannot  get  the  straight- jacket  and  the  two  phy- 
sicians out  of  her  mind.  She  states  that  she  had  a  sleeping 
potion  every  evening.  She  is  sure  from  the  way  she  felt  when 
she  got  up  that  someone  slept  with  her  every  night.  I  asked 
her  how  that  could  be  since  she  had  a  night  nurse,  but  she  said 
that  didn't  matter. 

Therapy  :    Residue,  plus  suprarenal,  plus  placental. 

Diagnosis  :  Psychosis,  at  the  bottom  of  which  is  a  thyroid 
plus,  adrenal  medulla  plus,  and  pituitary  post.  plus. 

The  patient,  as  her  family  state,  is  now  a  great  burden. 
She  takes  little,  if  any,  interest  in  the  children,  cares  nothing 
for  her  home  life,  and  is  totally  different  from  the  quiet,  domes- 
tic type  which  she  formerly  represented.  She  goes  out  to 
dances,  is  by  no  means  particular  in  the  choice  of  her  male 
companions,  and  is  continually  looking  for  and  craving  excite- 
ment. 

It  could  be  well  stated  that  this  patient  represents  a  point 
only  half  way  back  to  the  normal  from  her  state  of  acute 
psychosis.  This  half  way  state,  as  we  might  call  it,  depicts 
a  type  by  no  means  uncommon,  especially  at  the  present  time. 
There  are  many  individuals  of  the  mental  and  pschycic  state 
now  represented  by  the  patient's  present  behavior,  many  of 
whom  may  at  a  subsequent  period  go  on  to  a  condition  repre- 
sented by  this  patient  when  at  her  worst. 

The  precipitate  labor  means  to  me  a  marked  overactivity 
of  the  posterior  pituitary.    I  consider  this  psychosis  a  pituitary 


CASES  457 

anomaly  and  the  history  as  well  as  the  patient's  delusions  and 
hallucinations,  which  were  distinctly  of  a  sex  nature,  point  to 
this  important  cerebral  endocrine  structure  as  the  cause  of  her 
post  partum  mania  and  her  subsequent  symptomatology. 


October  21,  1916. 
MRS.  H. 

Operated  for  right  ovarian  cyst  size  of  4  months'  preg- 
nancy. 

March  5,  1920.  Soreness  of  the  right  side,  pains  in  the 
back  of  her  head  and  neck,  morbid  and  depressed,  sleepless, 
takes  long  to  fall  asleep. 

Has  one  child;  maternal  instinct  marked,  extremely  fond 
of  children;  good  sex  instinct.  Good  color;  blushes  and 
flushes  readily. 

Examination :    O.  K. 

Diagnosis :  Post,  pituitary  excess  and  adrenal  medulla 
excess. 

Therapy:  Anterior  pituitary  plus  placenta.  (Should  add 
cortex. ) 

Post,  pituitary  overactivity  is,  I  believe,  closely  related  to 
production  of  ovarian  tumors,  uterine  adenoids,  and  fibro- 
myomata. 


May  1,  1920. 
MRS.  O. 

Married  11  years;  2  para,  the  second  2>4  years  ago. 
Nursed  2  months,  with  amenorrhea  for  3  months. 

Menstruation  Q.  24  days,  duration  5  days. 

Premenstrual  phenomena,  nausea. 

Complaint :  Is  nervous,  fearful,  has  headaches  occipital, 
and  over  the  right  eye.     These  are  worse  at  menstruation. 

Examination :     Small  uterus,  cystocele  and  rectocele. 

The  patient  is  not  tall,  but  is  broad  and  thick  chested ;  is 
plump  and  has  a  beautiful  complexion.  Has  a  slight  mustache. 
Resembles  markedly  a  patient  of  mine,  whose  condition  is 
considered  to  be  due  to  the  adrenal  cortex.     The  question  is 


458  THE   ENDOCRINES 

whether  we  are  dealing  with  adrenal  or  pineal  adiposity.  The 
condition  which  prompts  the  headaches,  nervousness  and  fear 
is  viewed  by  me  as  posterior  pituitary,  whether  or  no  the 
pineal  is  likewise  involved.  The  therapy  advised  to  her  phy- 
sician, with  whom  she  was  seen,  is  mammary  extract  plus 
thymus,  because  of  her  24  day  menstruation.  To  this  was 
added  ovarian  residue  and  .pineal  gland.  The  patient  is 
anxious  to  conceive. 


April  27,  1920. 
MRS.  A. 
Married  seven  and  a  half  years,  no  para. 
Menstruation  began  at  14  years;  occurred  every  6  to  8 
months. 

It  then  became  regular  till  she  was  18  years  of  age,  when 
she  would  bleed  twice  a  month. 

Since  her  marriage  she  menstruates  every  5  weeks,  but 
for  one  day  only. 

She  skipped  her  menstruation  in  December. 

Had  measles  at  7  years,  pleurisy  3  years  ago,  influenza 
2  years  ago. 

Complaint:  Pain  in  the  right  side  for  a  year  and  a  half; 
headache. 

Premenstrual :  One  week  fullness  of  the  breasts,  pain  in 
the  right  side,  irritable. 

She  is  always  afraid,  especially  since  the  death  of  her 
mother,  when  the  patient  was  13  years  old.  She  wakes  up  at 
night  and  is  afraid  something  is  going  to  happen. 

Libido  marked  up  to  a  month  ago. 

Examination :    Corpus  luteum  cyst  of  the  right  ovary. 

Blood  pressure  100,  pulse  90. 

Therapy :     Suprarenal. 

May  4,  1920.     Pressure  100,  pulse  80. 

Therapy :    Ovarian,  ov.  residue,  thyroid,  suprarenal. 

May  12,  1920.     Feels  much  better,  therapy  continued. 


CASES  459 

March  17,  1920. 
M.    B. 

Married  7  years ;  0  para ;  0  abort. ;  0  op. 

Eight  years  ago  hurt  her  back  with  a  fall  and  since  then 
menstruates  every  3  weeks.  Menstruation  began  at  1 1  years ; 
is  now  regular  every  3  weeks,  lasting  a  week. 

Had  pneumonia  three  time.  Fifteen,  ten  and  three  years 
ago.  "Had  influenza  every  year."  Had  mumps  and  chicken- 
pox  as  a  child  and  two  years  ago  had  measles.  Her  brother 
had  pneumonia  twice.  Her  father,  who  was  a  physician,  died 
of  "septic  poisoning"  after  demonstrating  at  a  hospital  on  a 
dead  body. 

Has  psoriasis  every  since  she  began  to  menstruate.  She 
formerly  had  headaches  in  the  back  of  her  head,  radiating 
down  her  neck  and  behind  her  ears. 

Has  a  husky  voice  resembling  that  of  people  who  are 
hard  of  hearing,  so  that  I  spoke  loudly  to  her  until  I  asked 
her  about  her  hearing.  She  said  it  was  normal.  She  blushes 
and  flushes  easily  and  looks  like  another  patient  of  mine  (in 
fact  she  looks  enough  like  her  to  be  her  sister),  in  whom  fears 
and  phobias  are  the  predominant  symptom.  Some  days  she 
passes  much  urine,  some  days  little. 

Complaint :     Extremely  nervous  for  3  months. 

Premenstrual  phenomena:  "Always  feels  extra  fine  be- 
fore she  bleeds." 

She  "spots"  off  and  on.  She  is  "afraid"  and  despondent; 
"time  hangs  heavy  on  her  hands";  her  eyes  are  prominent; 
she  is  constipated. 

Examination :  Uterus  enlarged.  Contains  a  fibroid  nodule. 

Therapy :  Ovarian  residue,  plus  suprarenal,  plus  placental. 


May  15,  1920. 
MRS.  B. 
Married   10  years,  0  para,  0  abort,  op.   14  months  ago, 
dilatation  of  cervix,  removal  cystic  right  ovary,  removal  ap- 
pendix. 

Menstruation  began  at  13  years,  regular,  3  days'  dura- 


460  THE   ENDOCRINES 

tion,  accompanied  by  dysmenorrhea,  which  improved  after 
marriage. 

Premenstrual  phenomena  as  a  girl  lasted  a  week,  consist- 
ing of  pain,  depression  and  weakness. 

Now  feels  better  and  stronger  one  week  before  menstrua- 
tion than  at  any  other  time. 

Menstruation  for  the  last  6  years  lasts  only  one  day.  In 
the  last  4  years  has  gained  20  pounds. 

As  a  girl  was  healthy  and  well,  stopped  school  at  16,  but 
continued  with  her  music,  her  ambition  being  to  become  a 
singer,  which  wish,  because  of  her  illness,  has  never  been 
gratified. 

Has  had  chickenpox,  measles  and  mumps. 

Twelve  years  ago  she  noticed  the  first  change.  Her 
mother  had  been  ill  for  a  year  in  a  hospital  and  she  was  untir- 
ing in  her  attentions.  She  was  going  home  on  the  elevated 
train  and  was  suddenly  afraid  that  she  was  going  to  do  some- 
thing to  herself.  When  she  reached  home  her  menstruation 
had  begun. 

When  in  the  company  of  people  she  has  a  feeling  as  if 
her  throat  was  tightly  closed. 

The  presence  of  strangers  brings  on  and  accentuates  this 
annoyance  and  she  has  a  "hard  time  breathing."  She  cannot 
go  to  the  cinema  or  theatre  and  cannot  be  alone  because  of  the 
physical  fear,  that  is,  the  fear  that  she  might  die  in  one  of 
these  attacks.    Has  no  other  phobias. 

A  brother  is  at  Saranac  because  of  pulmonary  tubercu- 
losis. 

She  is  tall,  well  built.  For  the  last  4  years  has  acne  on 
the  chin,  the  acne  dating  almost  from  the  time  her  menstrua- 
tion became  less. 

Is  an  excellent  talker  and  her  memory  is  perfect. 

Irritation  of  the  skin  causes  a  white  line  and  then  a  very 
slow  but  marked  red  line.  There  is  no  blushing.  Has  marked 
varicose  veins  in  both  popliteal  spaces,  . 

Pulse  80,  pressure  125. 

Pelvic  examination :    Very  small  atrophic  uterus. 


CASES  461 


Therapy:     Placental,  ovarian  residue.     Slow,  steady  im- 
provement.    Patient  and  husband  comment  on  the  change. 


April  23,  1920. 
MRS.  C.  V. 

Married  8  years;  2  para.,  the  last  3  years  ago;  nursed  for 
3  months. 

Menstruation  regular,  5  days'  duration.  For  the  past 
few  months  loses  more  blood  and  now  has  been  spotting  for 
ten  days. 

Severe  headache. 

One  month  ago  severe  occipital  headache. 

One  week  ago  severe  occipital  headache,  pain  between  the 
shoulders  and  pain  running  down  the  back  of  the  legs. 

Diphtheria  seven  years  ago ;  treated  by  anti-toxin ;  was  in 
bed  for  5  months  with  extremely  rapid  pulse. 

Examination.    Retro  version ;  lacerated  cervix. 

She  is  nervous,  "on  edge,"  doesn't  know  what  to  do  with 
herself,  "feels  like  running  away." 

Blood  pressure  170;  pulse  115  when  sitting  up;  105  when 
lying  down. 

Diagnosis:  Involvement  of  the  adrenals  and  posterior 
pituitary ;  in  other  words,  posterior  pituitary  plus. 

Therapy :    Mammary,  thymus  and  placenta. 

April  30,  1920.  Blood  pressure  130,  since  taking  pre- 
scription. Headache  and  pains  have  disappeared  and  she  feels 
like  a  different  person.  Though  rarely  having  dreams,  she 
has  during  the  week  dreamed  of  holdups,  robbers  and  intoxi- 
cated people,  etc. 

May  7.    Tired,  sleepy. 

May  14.     Pressure  120,  pulse  90. 

Therapy:     Placenta,  thyroid,  suprarenal. 

May  21.    Pressure  120,  pulse  100. 

May  28.  Mammary,  thymus  and  placenta.  Feels  per- 
fectly well.     Pressure  110. 


462  THE   ENDOCRINES 

MRS.  G. 

May  24,  1920.  Last  menstruation  February  14th,  Has 
had  2  children,  one  in  1912,  one  in  1918. 

First  was  lost  when  1^  years  old,  with  an  unusual  cere- 
bral condition  diagnosed  as  meningitis,  after  an  illness  of 
several  weeks. 

The  second  baby,  likewise  a  girl,  blue  eyed  and  with  red- 
dish hair,  was  diagnosed  when  7  months  of  age  as  a  case  of 
amaurotic  family  idiocy.  This  child  lingered  until  the  end 
of  May,  1920. 

The  patient's  husband  lost  his  father  of  "Bright's  disease" 
at  the  age  of  60.  His  mother  died  of  Carcinoma  of  the  rec- 
tum at  the  age  of  60.  A  brother  died  of  typhoid.  A  sister, 
who  is  a  patient  of  mine,  has  reddish  hair  and  blue  eyes  and  is, 
though  apparently  normal,  mentally  and  physically  peculiar. 

The  patient  (Mrs.  G.)  has  sandy  hair  and  gray  eyes, 
wonderfully  smooth  skin,  without  the  faintest  suggestion  of 
trichosis. 

Her  father  has  dark  eyes,  the  mother  has  hazel  gray  eyes. 

A  brother  of  the  patient  is  blond  with  blue  e};es.  One 
sister  is  dark,  with  black  eyes,  and  considerable  trichosis.  An- 
other sister  is  dark,  with  black  eyes,  and  is  markedly  a  case 
of  hypertrichosis. 

The  patient,  with  her  coloring,  is  not  at  all  unlike  the 
peculiar  sister  of  the  husband. 

The  amaurotic  baby,  in  my  opinion,  was  characterized 
by  a  lack  of  the  endocrines  supplying  pigments,  which  factor 
could  readily  explain  the  conditions  of  sight  and  cerebral  mal- 
development. 

The  patient  has  blood  pressure  of  110,  and  pulse  of  100, 
and  will  be  given  during  this  pregnancy  suprarenal  extract  and 
pituitary  anterior,  in  other  words,  two  of  the  important  so- 
called  male  glands.  The  theory  in  this  case  instances  the  line 
along  which  unsolved  problems  of  medicine  must  be  ap- 
approached.  If  the  new  baby  is  a  boy  or  inherits  the  dark  su- 
prarenal cortex  character  of  the  maternal  grandfather,  it  is 
probable  that  all  will  be  well.     If,  however,  the  expected  off- 


CASES  463 

spring  is  of  the  type  of  the  other  two  children,  suprarenal  cor- 
tex and  pituitary  anterior  will  be  administered  continually 
from  the  day  of  birth.  Aside  from  the  above  mentioned  ex- 
tracts, extract  from  the  cells  of  Leydig  and  of  the  interstitial 
portion  of  the  ovary  are  to  be  taken  into  consideration.  These 
four  extracts  will  be  administered  to  the  expectant  mother  dur- 
ing the  whole  period  of  her  pregnancy. 

The  element  of  heredity  with  its  associated  gland  activi- 
ties plays  an  important  part  in  determining  the  type  of  child 
born.  Many  women,  who  eat  much,  have  small  babies,  and 
many  who  eat  little,  have  large  babies.  Babies  of  big,  bony 
framework,  well  covered  with  muscular  tissues,  are  the 
products  not  of  the  food  which  the  mother  eats,  but  of  their 
inherent  endocrine  activities,  such  as  the  hypophysis,  etc.  I 
recently  confined  a  patient  whose  newly  born  infant  was  one 
of  the  lustiest  and  pinkest  I  have  ever  seen.  The  delivery  was 
perfectly  normal.  Yet  half  an  hour  after  birth  the  baby  had 
the  most  typical  attack  of  tetany,  which  lasted  for  an  hour, 
gradually  growing  less,  and  entirely  fading  away  in  the  course 
of  24  hours.  The  baby  is  perfectly  normal.  In  neither  side 
of  the  family  did  I  elicit  a  history  bearing  directly  on  the 
etiology,  yet  I  know  enough  of  the  ancestry  to  recognize  the 
existence  of  thyroid  and  of  pituitary  anomalies.  The  baby's 
mother,  for  the  last  10  weeks  of  her  pregnancy,  was  in  bed 
with  a  grippe  cold.  In  view  of  a  probable  parathyroid  etiology 
of  tetany,  and  the  recorded  observations  as  to  the  relations  of 
this  condition  to  the  subsequent  development  of  nervous  mani- 
festations, among  them  chorea  and  epilepsy,  any  observation 
of  this  sort  is  of  the  greatest  importance.  Had  this  baby  been 
put  into  its  little  basket,  and  had  no  attention  been  paid  to  it 
for  the  first  hour  and  a  half  after  delivery,  the  tetany  would 
have  escaped  notice,  as  the  typical  movements  of  the  arms, 
the  mouth  and  the  larynx  diminished  quickly 


464  THE    ENDOCRINES 

MRS.    P. 

September  14,  1914.  Two  para,  the  last  7  months  ago, 
Nursed  for  6  months. 

Menstruation  regular,  but  lasts  8  days. 

Complaint :  Backache,  headaches,  nervousness,  pain  on 
the  left  side  under  the  lowest  costal  cartilages. 

Uterus  enlarged,  hard,  irregular,  containing  several  small 
fibroids.     Ovaries  cystic. 

Operation,  Curettage;  Laparatomy,  uterine  suspension, 
resection  half  of  each  ovary. 

May  17,  1920.  A  drawing  feeling  under  the  left  rib. 
Sleeps  poorly,  has  frontal  headaches,  stiffness  of  the  neck. 
Has  just  lost  2  aunts;  one  died  of  carcinoma,  the  other  of 
heart  trouble.  She  is  frightened,  having  heard  so  much  about 
cancer. 

Examination:  No  abnormaHty.  Blood  pressure  110, 
pulse  88. 

Therapy :     Placental  extract  and  ovarian  extract. 

May  24,  1920.  Sleeps  much  better  and  feels  languid. 
Her  menstruation  came  on  4  days  ahead  of  time,  probably 
because  of  the  ovarian  extract.     Pressure  110,  pulse  72. 

Therapy:    Placental  extract  and  suprarenal. 

June  1,  1920.  Has  slept  much  better;  feels  sleepy  all  the 
time.     Pressure  100,  pulse  88. 

The  effect  of  the  placental  extract  in  this,  as  in  many 
other  cases,  is  to  promote  sleep  and  create  a  feeling  of  languor, 
which  I  take  to  be  one  of  the  many  evidences  of  its  action  in 
antagonizing  probably  the  adrenal  medulla,  but  much  more 
specifically  the  posterior  pituitary.  The  posterior  pituitary 
activity  in  this  patient,  as  in  innumerable  others,  is  not  asso- 
ciated with  high  blood  pressure  because  the  thyroid  is  not 
minus.  This  gives  an  indication  as  to  therapy  and  for  that 
reason  thyroid  was  not  administered  in  this  case.  Patient  feels 
better  physically  and  mentally.  It  is  not  to  be  doubted  that 
the  physical  and  pelvic  examination,  with  the  assurance  that 
all  was  normal,  had  much  to  do  with  calming  the  patient  and 
removing  her  fears. 


CASES  465 

MRS.  A.  V. 

November  15,  1917.  One  para,  21  years  ago;  0  abort., 
Oop. 

Menstruation  Q.  26  days,  large  amount,  no  pain. 

Complaint :      Menorrhagia. 

Examination :  Enlarged  uterus,  hypertrophy  of  cervix. 
Diagnosis,  fibrosis  uteri. 

Therapy:  Ergotin  2  grs.,  stypticin  gr.  1^  in  capsule 
form  3  times  a  day. 

September  27,  1918.  Complaint:  Menorrhagia  and 
asthenia. 

Therapy :  Ergotin,  extract  of  nux  vomica  and  quinine 
hydro-bromide. 

March  4,  1920.  Complains  of  menorrhagia  and  marked 
asthenia. 

Examination :     Large  uterus,  hypertrophy  of  cervix. 

Therapy:  Ovarian  extract,  plus  thyroid,  plus  mammary, 
plus  suprarenal. 

Last  menstruation  April  22nd. 

June  1.  Patient  feels  better  in  every  way,  has  gained  in 
weight,  and  wonders  if  she  is  gravid. 

Examination:  Small  uterus  and  cervix,  at  least  1/3  less 
than  normal  uterus  and  certainly  1/4  the  size  of  the  uterus 
when  examined  on  March  4,  1920.  There  are  no  flushes  and 
it  is  probable  that  as  a  result  of  the  therapy  the  mammary 
extract  and  the  suprarenal  and  the  thyroid  have  resulted  in  a 
marked  involution  such  as  should  normally  take  place  in  a 
patient  in  the  late  forties. 

The  ovarian  extract  and  the  thyroid  were  overcome  in 
their  uterine  nutritional  functions  by  the  suprarenal  extract 
and  especially  by  the  mammary. 


-      MRS.  L. 
A  patient  pregnant  in  the  ninth  month  had  a  slight  in- 
fluenza.    A  week  after  recovering  from  her  slight  influenza, 
she  came  to  me  and  immediately  began  to  cry.     She  said  she 
was  irritable,  restless,  could  scarcely  sit  down,  felt  the  impulse 


466  THE    ENDOCRINES 

to  be  continually  on  the  move,  felt  frightened  and  knew  there 
must  be  something  the  matter  with'  her,  because  she  had  never 
felt  like  this  before  and  wished  she  could  have  her  baby  right 
away.  Knowing  her  for  two  years  or  more  and  having  confined 
her  with  her  second  baby,  and  seeing  her  before  and  after  labor 
and  under  all  conditions.  I  knew  her  to  be  a  very  sensible 
wife,  mother  and  patient.  It  was  apparent  at  a  glance  that 
she  had  a  slight  thyroiditis  among  her  other  gland  involve- 
ments, and  that  the  adrenals  and  pituitary  were  disturbed. 
She  had  a  rapid  pulse,  and  was  for  the  time  being  a  case  of 
hyperthyroidism  with  psychic  irritation.  (Ov.  Ext.  and  su- 
prarenal extract  were  given.) 

We  know  that  during  pregnancy  there  is  increased  glandu- 
lar activity  of  the  anterior  hypophysis;  we  know  that  the 
suprarenal  glands  and  the  thyroid  especially,  and  probably  all 
the  other  endocrines,  are  working  with  increased  energy.  It 
can  be  readily  realized  that  pregnant  women  are,  therefore, 
more  subject  perhaps  to  injury  of  one  or  more  of  the  endo- 
crines than  are  the  non-pregnant.  They  recover  more  slowly 
from  the  cough  and  the  bronchial  irritation  of  the  present  epi- 
demic (1920).  In  the  epidemic  of  1918-1919,  the  mortality 
in  pregnant  women  was  very  great,  probably  because  the  endo- 
crines of  the  pregnant  woman,  working  over-actively  through 
the  stimulation  of  pregnancy,  are  more  readily  devitalized  by 
the  toxins  of  influenza.  She  improved  slowly  but  steadily  and 
was  well  before  full  term. 

I  confined  this  patient  subsequently  and  she  is  now  per- 
fectly normal. 


MRS.  M. 

The  moment  the  patient  entered  the  office  with  her  hus- 
band I  said,  "How  long  has  your  neck  been  so  large?"  The 
thyroid  was  transversely  and  evenly  enlarged.  She  answered, 
"That's  what  brought  me  here." 

Md.  35/2  years,  1  para,  lYz  years  ago.  Nursed  15  months 
and  for  the  first  6  months  of  nursing  she  did  not  menstruate. 

Menstruation    every   5    weeks,    8   days'    duration.      Last 


CASES  467 

menstruation  November  28th,  1919,  and  is  now  pregnant 
again. 

When  6  months  pregnant  with  her  first  baby,  she  observed 
cardiac  palpitation;  which  became  worse  after  the  birth  of  her 
baby. 

Since  she  became  pregnant  the  second  time  the  thyroid 
has  enlarged  still  more  and  she  has  attacks  of  palpitation,  last- 
ing for  hours,  during  which  time  she  is  frightened  and  demands 
the  presence  of  her  physician  for  hours. 

As  I  take  her  history  she  talks  continuously  and  I  can 
scarcely  stop  her  to  take  the  history ;  she  insists  on  telling  me 
what  other  physicians  have  told  her  and  is  scarcely  able  to  sit 
quiet  or  to  be  composed. 

Note:  Since  the  anterior  pituitary  is  stimulated  during 
pregnancy  the  thyroid  is  probably  stimulated  to  a  development 
of  its  interstitial  tissue. 

Therapy :  Pituitary  post,  plus  placenta,  plus  ovarian 
residue. 

March  \Qth,  1920.  Thyroid  noticeably  smaller  and  soft- 
er; patient  quiet  and  composed;  blood  pressure  90. 

Note:  High  blood  pressure  is  often  associated  with  thy- 
roid minus.  Thyroid  minus  is  responsible  for  kidney  condi- 
tions simulating  nephritis.  Hence  for  years  I  have  given  thy- 
roid extract  for  pregnancy  kidney,  and  for  pre-eclamptic  symp- 
toms. Patient  w^as  assured  that  thyroid  plus  w^as  much  more 
helpful  to  her  than  thyroid  minus.  Undoubtedly  the  condition 
of  thyroid  minus  as  is  to  be  noted  in  the  history  of  Mrs,  K. 
(p.  436)  represents  the  opposite  state  to  this  patient's  condition 

She  is  remarkably  improved.  Thorough  explanations  of 
the  condition  was  an  important  part  of  the  therapy. 


MRS.  MacD. 
This  patient  came  to  me  when  four  months  pregnant. 
She  was  of  an  excitable,  joyous  and  rather  jerky  nature,  with 
a  very  settled  sound-minded  understanding  husband.  A  w^eek 
later,  while  standing  beside  her  automobile  on  a  country  road, 
because  of  a  blow-out,  there  w^as  a  loud  screeching,  grinding 


468  THE    ENDOCRINES 

noise  caused  by  an  automobile  which  came  suddenly  and  at 
rapid  speed  around  a  by-road  a  few  yards  away.  The  automo- 
bile turned  into  the  main  road  at  rapid  speed,  and  the  patient 
standing  by  the  rear  mud-guard,  with  marked  presence  of 
mind,  pushed  her  body  and  abdomen  against  her  automobile 
while  the  guard  of  the  onrushing  machine  scraped  and  pushed 
her  thighs  and  buttocks  against  her  own  car.  When  I  saw 
her  she  was  rather  upset  by  her  experience,  her  sciatic  region 
and  buttocks  were  black  and  blue.  She  was  kept  in  bed  for 
several  days  with  sedatives  and  no  ontoward  result,  so  far  as 
her  pregnancy  was  concerned,  developed.  During  labor  her 
membranes  ruptured  before  full  dilatation.  She  was  delivered 
of  a  nine-pound  boy. 

She  was  exceedingly  fearful  concerning  the  child,  in- 
sisted on  its  being  by  her  bedside  all  the  time,  and  wanted  it 
in  her  own  bed  continually.  She  was  rather  critical  of  the 
nurse,  who  was  exceedingly  capable.  Her  nipples  were  re- 
tracted and  the  milk  was  extracted  by  pump  and  given  to  the 
baby,  which  thrived  very  well.  She  was  given  suprarenal  ex- 
tract with  anterior  pituitary ;  there  was  quite  a  noticeable  im- 
mediate improvement  in  every  way;  her  fears  and  suspicions 
rapidly  disappeared. 


MRS.  L. 
When  this  patient  came  to  me  I  saw  that  she  was  nervous 
and  fearful.  I  explained  to  her  that  she  should,  during  her 
pregnancy,  not  listen  to  any  of  the  numerous  and  foolish  things 
that  she  would  hear  from  other  women,  that  everything  wai 
normal,  and  that  any  explanation  that  she  desired  would  be 
gladly  given  by  me.  I  saw  her  as  I  see  all  pregnant  patients, 
every  two  weeks,  and  it  was  a  continued  struggle  on  my  part 
to  remove  from  her  mind  the  strangest  notions  concerning 
prenatal  influence.  As  her  husband  said,  "She  ate  up  every- 
thing she  heard."  During  the  last  three  months  a  favorite 
sister  of  hers,  who  had  previously ,  been  operated  on  for  a 
carcinoma  of  the  coecum,  was  seized  with  an  intestinal  ob- 
struction and  shortly  after  died.     Two  weeks  before  the  ex- 


CASES  469 

pected  date,  realizing  the  patient's  condition  of  fear  and  fright, 
I  sent  her  to  the  obstetric  sanitarium  in  charge  of  a  nurse  to 
remove  her  from  the  surroundings  and  the  people  whose  influ- 
ence I  felt  was  injurious.  She  was  exceedingly  hard  to  quiet. 
When  she  went  into  labor  she  was  frightened,  said  she  knew 
she  was  going  to  die  and  talked  continually  of  her  sister.  Her 
membranes  ruptured  before  pains  began  and  the  dry  labor 
was,  of  course,  rather  long.  I  felt  that  the  loss  of  her  baby 
would  be  followed  by  a  psychosis  and  I  carried  her  along 
with  small  doses  of  pituitrin,  and  toward  the  end,  I  anesthe- 
tized her  by  chloroform,  split  the  perineum  and  delivered  her 
safely.  She  was  watchful  of  the  baby,  insisted  on  its  being 
near  her  all  the  time,  watched  the  nurse  in  every  manipulation, 
complained  that  she  was  not  holding  the  baby's  head  in  the 
right  position.  Although  the  day  nurse  was  exceedingly 
capable,  I  changed  nurses  and  explained  to  the  new  one  the 
patient's  condition ;  that  she  was  bordering  on  a  psychosis  and 
that  she  should  be  exceedingly  yielding  in  everj^thing  that  the 
patient  asked.  I  told  the  patient  that  she  would  be  asked  to 
nurse  the  baby  for  only  two  weeks  in  order  to  get  the  uterus 
back  to  normal  condition,  and,  thereafter,  the  baby  would  be 
put  on  the  bottle.  I  gave  the  patient  suprarenal  extract,  grains 
2,  plus  anterior  pituitary,  grains  2,  three  times  a  day.  At  the 
end  of  two  weeks  I  turned  the  baby  over  to  the  paediatrist. 
In  the  meantime,  though  I  had  explained  my  reasons  to  the 
patient's  husband,  and  particularly  to  her  mother,  they  had, 
without  my  knowledge,  told  her  that  she  was  selfish  in  not 
wishing  to  nurse  and  the  mother  said  it  was  a  gross  injustice 
to  the  baby.  This  was  a  case  of  thyroid,  adrenal  (medulla), 
posterior  pituitary  over-activity  with  a  minus  of  the  adrenal 
cortex  and  anterior  pituitary. 

I  questioned  the  mother  at  one  time  as  to  her  daughter's 
condition  when  a  child.  She  answered  that  she  was  quite 
normal.  I  said,  "Wasn't  she  rather  nervous  and  afraid  as  a 
child?"  and  she  replied,  "Oh,  yes,  when  IMrs.  L.  was  a  little 
girl  about  five,  whenever  she  heard  a  band  of  music  she  would 
run  into  the  house  in  terror  and  either  stay  with  me  or  hide 


470  THE    ENDOCRINES 

herself."    The  patient  has  a  stubborn,  inconsiderate  husband. 
The  psychic  irritation  is  profound. 


MRS.  G. 

Patient  was  married  on  January  30th,  1917.  On  Febru- 
ary 21st,  1917,  she  menstruated  for  one  day.  On  March  20th, 
1917,  she  menstruated  for  one  day,  and  stated  that  her  sisters 
all  stained  for  one  day  even  when  pregnant.  The  patient  ex- 
pected to  be  delivered  on  November  10th,  1917,  but  was  de- 
livered in  December,  1917.     She  felt  life  on  July  12th,  1917. 

I  saw  her  first  on  September  21st,  1917,  because  her 
home  was  in  Virginia  and  after  she  came  to  New  York  she 
was  referred  to  me.  She  returned  home  four  weeks  after  the 
delivery  and  contrary  to  my  advice  nursed  her  baby  for  eleven 
months,  during  which  time  she  did  not  menstruate.  She  then 
returned  to  New  York  and  her  mother  sent  for  me.  The  pa- 
tient was  in  bed,  pale,  tired,  languid,  almost  in  a  state  of 
amentia,  frightened,  stated  that  she  was  losing  her  mind  and 
fearful  concerning  every  detail  of  her  life.  She  was  told  that 
her  condition  was  the  direct  result  of  her  prolonged  lactation, 
that  in  giving  the  breast  to  the  baby  for  such  a  long  period 
she  had  deprived  herself  not  only  of  nourishment  needed  for 
her  own  system,  but  had  been  sucked  dry  of  the  endocrine 
elements  essential  to  her  welfare.  She  was  given  a  prescrip- 
tion consisting  of  suprarenal  extract,  grains  2,  thyroid  extract, 
grains  1/10,  and  pituitary  extract  whole  gland,  5  grains  T.I.D. 
The  baby  was  at  once  put  on  the  bottle  and  in  two  weeks 
there  was  a  complete  transformation,  both  physical  and  men- 
tal, and  in  six  weeks  she  was  entirely  restored  to  her  normal 
state  of  health. 

One  hears  frequently  of  the  inability  of  the  modern  gen- 
eration to  nurse  babies  at  the  breast.  Whatever  the  causes 
may  be,  and  I  think  I  know  the  reasons  for  this  inability,  it 
is  quite  certain  that  in  my  practice  at  least,  only  a  few  of  the 
mothers  should  nurse  the  babies  without  the  aid  of  endocrine 
stimulation,  and  this  endocrine  therapy  is  not  administered 
to  improve  the  amount  or  quality  of  the  milk,  for  plenty  of  the 


CASES  ^7 1 

mothers  have  milk  of  a  quantity  and  quahty  sufficient  to  cause 
an  increase  in  the  baby's  weight  of  from  5  to  12  ounces  per 
week.  This  much  I  do  know  about  lactation,  that  in  many  of 
these  cases  the  mothers  are  drained  of  their  endocrine  reserve 
and  the  strain  on  the  adrenals  is  not  the  least  of  the  injurious 
effects.  It  is  a  constant  battle  between  me  and  the  paediatri- 
tian.  He  naturally  thinks  only  of  the  baby.  It  is  gaining  in 
weight,  and  he  sees  no  reason  for  prescribing  a  formula.  But 
I,  who  am  supposed  to  have  the  interests  of  the  mother  at 
heart,  feel  that  in  many  cases  we  are  doing  great  harm  to  the 
reser^-e  energy  of  the  mother,  and  the  stand  which  I  take 
against  prolonged  or  unaided  nursing  is  in  many  cases  posi- 
tive. Then  again  comes  the  battle  with  the  patient's  mother 
or  mother-in-law  or  relatives  who,  because  they  nursed  sev- 
eral children  in  their  day,  see  no  reason  why  the  attending 
obstetrician  should  advise  othenvise. 


MRS.  M. 

I  confined  a  patient  in  a  hospital  at  two  o'clock  in  the 
morning.  At  seven  there  was  a  fire  in  a  closet  containing 
drugs,  and  her  room  and  the  corridors  were  filled  with  smoke. 
The  nurse  was  out  of  the  room  at  the  moment,  the  patient 
groped  her  way  to  the  crib,  took  her  babe  in  her  arms  and 
walked  up  four  flights  of  stairs.  When  I  saw  her  after  she 
had  been  put  to  bed  in  another  room,  she  was  not  frightened 
but  was  angry  and  was  complaining  of  what  she  called  "the 
poor  management"  of  the  institution. 

Had  her  adrenal  and  pituitary  function  been  minus,  she 
would  have  lost  her  head,  would  have  shown  the  physical 
manifestations  of  fear,  would  have  become  as  it  is  called  "hys- 
terical," etc.  Having,  however,  a  good  adrenal  response 
(both  medullary  and  cortical)  she  was  self-possessed  and  able 
to  do  the  right  thing.  Her  maternal  instinct  played  an  im- 
portant part  in  producing  this  response  which  shows  that  her 
posterior  pituitary  also  acted  when  called  upon.  The  asso- 
ciated action  of  the  anterior  pituitary  was  responsible  for  the 
judgment  displayed  under  unusually  trying  conditions. 


472  THE   ENDOCRINES 

The  self-possessed  person  is  one  whose  endocrine  mech- 
anism needed  at  the  moment  or  for  a  definite  purpose  is  stable 
and  intact  without  interference  by  or  without  excitation  of  as- 
sociated reactions  able  to  block  or  to  interfere  with  or  com- 
plicate the  co-ordinate  mechanism  supposed  to  play  the  im- 
portant part  or  role  correctly. 

Any  deviation  from  this  by  what  are  known  as  conflict- 
ing emotions  means  that  under  certain  circumstances  self-pos- 
session is  lost.  This  gives  rise  to  conditions  familiarly  known 
as  "loss  of  control,"  "becoming  rattled,"  "stage  fright,"  "giv- 
ing one's  self  away." 

Now  this  patient  was  taken  home  in  an  ambulance,  thus 
removing  her  from  the  surroundings  associated  with  the  ex- 
perience. She  was  told  to  think  of  it  as  a  wonderful  proof 
of  her  nerve  and  courage  and  to  realize  that  she  should  be  most 
grateful  for  the  favorable  outcome  and  not  spoil  her  breast 
milk  by  anything  that  would  repress  her  happiness  and  gen- 
eral sense  of  well-being. 

She  has  not  shown  the  faintest  unfavorable  reaction,  is 
quite  proud  of  the  compliments  showered  on  her  by  her  friends 
and  family  and  has  shown  such  a  marked  "nerve  and  endo- 
crine stability"  that  the  man  may  be  considered  fortunate  who, 
twenty  years  hence,  marries  the  little  baby  daughter  whom  I 
brought  into  the  world.  For  such  an  endocrine  heredity  as  is 
this  baby's  is  not  to  be  lightly  viewed. 


MRS.  W. 
Pregnant  three  and  a  half  months,  not  nauseated,  some- 
what sleepy.  Had  a  grip  cold  and  was  treated  by  a  physician 
who  after  four  days  said  she  was  alright.  Three  days  later 
when  Dr.  T.  was  called  in  he  found  her  mentally  irrational, 
passing  eight  to  twelve  ounces  of  urine  a  day  with  a  tempera- 
ture of  101^.  The  urine  contained  alb.  and  casts.  He  gave 
her  acetate  of  potash  and  colonic  irrigations  of  sodium  bicarb, 
and  the  urine  went  up  to  thirty-six  ounces.  When  I  saw  her 
her  knee-jerk  was  exaggerated,  her  blood  pressure  was  110, 
she  answered  all  questions,  had  no  facial,  tongue  or  hand 


CASES  473 

paralysis  or  paresis,  but  was  sleepy  and  drowsy.  My  diag- 
nosis was  acute  nephritis  with  intracerebral  pressure  and  hy- 
pothyroidism, because  of  the  slow  pulse. 

When  first  seen  she  was  passing  only  ten  or  twelve  ounces 
of  urine  a  day  containing  alb.  and  casts.  In  this  patient  we 
see  as  the  result  of  influenza  a  kidney  condition  parallel  to 
many  of  the  pre-eclamptic  and  eclamptic  cases,  except  that 
the  blood  pressure  was  low.  In  the  pre-eclamptic  state  blood 
pressure  is  high  because  of  posterior  pituitary  overactivity.  In 
this  case  involvement  of  the  pituitary  (the  slightest  form  of 
encephalitis  lethargica)  resulted  in  a  posterior  pituitary  minus. 
In  eclamptic  cases  the  important  conditions  are  post,  pituitary 
excess  and  thyroid  minus.  This  patient  improved  and  be- 
came normal  on  a  quarter  of  a  grain  of  thyroid  three  times  a 
day  and  on  the  bicarb,  and  glucose  Murphy  drip. 


MRS.  L. 

Had  her  first  baby  and  a  few  days  after  developed  a  grip 
cold  which  I  think  she  also  had  before  her  labor.  I  saw  her 
with  Dr.  B.  She  developed  a  puerperal  mania  and  was  re- 
strained with  difficulty.  The  doctor  gave  her  morphine  and 
hyoscine.  Blood  pressure  normal,  pulse  above  normal.  No 
paralysis  or  paresis  but  the  knee-jerks  were  below  normal. 

She  answered  everything  I  asked  her.  Her  memory  for 
every  detail  was  excellent  and  she  said  she  thought  that  she 
had  wet  the  bed,  on  which  point  she  seemed  to  harp  contin- 
ually. She  thought  she  was  ''drunk  from  the  cognac  which 
the  doctor  gave  her  for  her  cold"  and  so  explained  the  enuresis. 
She  talked  continually  and  then  came  to  the  question  of  her 
former  physician,  on  which  she  harped  most  continually,  call- 
ing me  back  several  times  to  tell  me  more  details  of  his  neglect 
and  his  refusal  to  go  to  the  Bronx,  She  simply  could  not 
stop  talking;  wanted  her  baby  near  her  or  in  bed.  My  diag- 
nosis was  hyperthyroid  intoxication, — thyroiditis. 

Therapy :    Ovarian  extract  and  suprarenal  extract. 

Result — Rapid  recovery. 


474  THE    ENDOCRINES 

May  21,  1919. 
MRS.  G. 

Married  27  years ;  1  para  26  years  ago ;  1  abort.  23  years 
ago. 

Appendix  removed  4  years  ago. 

Menstruation  regular,  2  days'  duration,  no  pain. 

Premenstrual:      (1    week)    breasts,   draggy   feeling,   de- 
pression. 

Complaint :     Pain  in  the  right  side,  backache,  a  sense  of 
''dropping  down,"  dreams  much. 

Examination :    Possible  adhesions  about  the  uterus,  small 
fibroid  in  the  fundus. 

Therapy:     Mammary  extract,  plus  ergotin,  plus  pyrami- 
dom. 

September  6,  1919.     Polyp  of  the  cervix,  projecting  into 
the  vagina  and  not  seen  before. 

Note:     Probably  forced  out  by  mammary  extract  and 
ergotin. 

December  16,    1919.     Polyp  protrudes  from  the  cervix 
more  than  in  September. 

February  9,  1920.     Placental  extract  given. 

February  25,   1920.     Feels  tired  and  polyp  removed  in 
my  surgery.     Placental  extract  continued. 

March  10,  1920.     Feels  tired  and  languid  (effect  of  pla- 
cental extract),  legs  feel  like  paralyzed. 

March    10,    1920.     Therapy:     Suprarenal   extract,   plus 
pituitary  anterior,  plus  thyroid. 

June.      Thyroid    has   twice   increased   the   premenstrual 
shakiness  and  has  caused  tachycardia. 


September  24,  1917. 
MRS.  E. 
Married  one  and  a  half  years,  0  para. 
Menstruation  regular,  duration  10  days. 
Complaint:     Menorrhagia,   leucorrhea   and   pain  in  the 
pelvis. 

Examination:     Enlarged  uterus,  hypertrophy  of  cervix. 


CASES  475 

Therapy :     Thymus,  mammary,  ergotin ;  douches. 

September,   1918,  had  a  severe  attack  of  ureteral  colic. 

May  12,  1920.  Menstruation  regular,  duration  1  week, 
losing  considerable  blood.  Has  pain  in  the  left  side  and  head- 
aches at  menstruation. 

Vaginal  examination  permits  the  palpitation  of  the  left 
ureter  which  in  the  region  of  the  bladder  is  somewhat  thick- 
ened and  very  sensitive.  The  uterus  is  enlarged  but  freely 
movable. 

Therapy:     Mammary,  thymus,  placental. 

May  26.  Mammary,  thymus,  placental  ant.  pituitary. 
Feels  better;  looks  well. 


February  25,  1920. 
MRS.  I.  R. 

Married  3  years ;  0  para ;  0  abort. ;  0  op. 

]\Ienstruation  regular,  3  days'  duration;  pain  every  other 
month. 

Premenstrual :     ( 1  day)  languid  and  irritable. 

Complaint :     Why  not  gravid  ? 

Has  asthma  since  marriage  and  has  it  when  she  catches 
coid. 

Menstruated  profusely  before  marriage;  since  marriage 
menstruates  less  and  has  gained  25  pounds. 

Examination :    Small  uterus,  pin  hole  os,  retroflexion. 

One  year  ago  was  given  by  her  physician,  whose  wife 
while  under  my  care  became  pregnant  under  endocrine  therapy, 
corpus  luteum  and  thyroid.  Patient  states  that  asthma  came 
on  after  taking  those  capsules. 

My  therapy:  Ovarian  extract,  plus  thyroid,  plus  post, 
pituitary. 

March  7,  1920.  I  received  the  following  letter:  "I  am 
feeling  fine.  The  medicine  hasn't  affected  me  at  all.  I  have 
taken  all  the  capsules.  My  appetite  seems  to  be  better  than 
ever.  I  havn't  had  any  colds  nor  heavy  breathing  since  I  have 
seen  you." 


INDEX 


Abortiox,  endocrine  therapy  in,  179 
Acidosis  of  eclampsia,  211 

of  pregnancy,  high  colonic  irriga- 
tions   for,  215 
Acquisition,  instinct  of,  236 
Acromegaly,  67,  107,  295 

s>TTiptoms  of,  340,  341 
Adams   (Henry),  20,  21,  30 
Addison's  disease,  symptoms  of,  353 
Adipositas  dolorosa,  112 

universalis,  112 
Adrenalin,  336,  352 

action  of,  on  nervous  system,  280 

functions  of,  303 
Adrenals,  60,   116 

action  of,  in  fear,  304 

distribution  of,  351 

function  of,  303 

in  pregnancy,  76 

relation  to  growth,  162,  165 
Adrenin,  117 
Advice.  45 
Age  of  genital  maturity,  grov^'th  of 

skeleton  and,  relation  of,  151 
Aggression,  placental,  11 
Agoraphobia,  236 
Albuminuria  of  pregnancy,  201 
Alcohol,    effects   of,   on   endocrines, 

311 
Alcoholism,  145 
Amenorrhea,  65,  118 

and  pregnancy,  175,  188 

of  lactation  associated  with  lacta- 
tion atrophy,  dl 

of  pregnancy,  135 

physiological,  135 
Anaphylaxis,  280 
Anger,  emotion  of,  and  instinct  of 

pugnacity,  234 
Angioneurotic    edema,    relation    to 

menstruation,  159 


A.rtagonism  between  emotions  of 
sympathetic  and  cranial 
divisions  of  autonomic, 
autonomic  system,  284 
and  sacral  divisions  of  au- 
tonomic system,  285 
Antagonistic  endocrine  therapy  for 

pituitary  gland,  321 
Asthenia,  75,  11 
Atrophy,  lactation,  134 

associated  with  amenorrhea  of 
lactation,  61 
of  uterus  following  curettage,  68 
ovarian,  neuroses  with,  270 
Atropin,  action  of,  on  nervous  sys- 
tem, 280 
Autonomic  nervous  system,  280 

antagonism  between  emotions 

of  divisions  of,  284,  285 
Cannon's  resume,  281 

Balance  between  endocrines,  287 

in  individual  endocrines,  287 

sense  of,  9 
Barker,  250 
Bartels,  115 
Basedow's  disease,  104,  105,  222,  230, 

240,  244,  245,  290,  325,  328,  344, 

345,  346,  347 
Benedict  (Joan),  42 
Berry,  104 
Biedl,  95,  100,  101,  106,  123,  150,  151, 

155 
Blood-pressure,  113 

high,  in  pregnancy,  217 
Blundel,  94 

Breasts,  development  of,   132 
Butler  (Samuel),  45 

Cachexia  strumipriva,  101,  154 
thyreopriva,      morbus      basedowi 
and,  differentiation,  350 


477 


478 


INDEX 


Csesarean     section     for     eclampsia, 

211,  213 
Calcium  metabolism,  76 

and  ovary,  relation  of,  62 
Cannon,  117,  118,  281,  282,  283,  284, 

285,  286 
Cannon's      resume     of      autonomic 

nervous  system,  281 
Cardiac  diseases,  pregnancy  in,  203 
Cases,  reviev/  of,  397-475 
Castor  oil  for  production  of  labor, 

204 
Castration,  76,  128,  151,  155 

obesity  from,  114 
Catarrh,  cervical,  in  sterility,  172 
Cervical  catarrh  in  sterility,  172 
Change  of  life,  166,  168,  169,  338. 

See  also  Climacterium,  Menopause. 
Character,  determiners  of,  56,  57 
Characteristics,   sex,    differences   in, 
explanations  for,  298 
primary,  121 
secondary,  121 
Child,  future  of,  38 
Children,  curiosity  of,  21 

treatment  of,  4 
Chlorosis,  68 
Chorea,  89 

Chorioepithelioma,  209,  317 
Chromosomes,  56,  57 

sex,  57 
Chronic  benign  hypothyroidism,  102 
Church,  252 
Chvostek,  98 
Climacterium,  80,  161,  166,  168,  169. 

See   also  Menopause,   Change   of 
life. 

dermatoses  of,  160 

gl3Xosuria    of,    placental    extract 
for,  322 
Clinics,  review  of,  355-396 
Coitus,  excessive,  phobias  associated 

with,  305 
Colonic    irrigations,    high,    for    aci- 
dosis of  pregnancy,  215 
Coma  of  pregnancy,  feeding  during, 

216 
Congenital  myxedema,  101,  154 


Constitutional  dysmenorrhea,  65,  218. 
See  also  Dysmenorrhea,   constitu- 
tional. 
Construction,  instinct  of,  236 
Contra-suggestion,  237 
Convulsions.     See  Eclampsia. 
Corpus  luteum,  62,  64,  119,  123 

action   of   trophoblast  cells   on, 

in  pregnancy,  199 
extract    in    vomiting    of    preg- 
nancy, 201 
function  of,  197 
in  relation  to  fear,  273,  276 
Courage,  304 

Coyness,    female,    and    sexual   jeal- 
ousy, 236 
Cranial  division  of  autonomic  sys- 
tem, 282 
Cretinism,  59,  101 
Crime  and  delinquency,  255 
Criminality,   mental   deficiency  and, 

257 
Curettage,    atrophy    of   uterus    fol- 
lowing, 68 
in  sterility,  171 

dangers  of,  184,  185 
Curiosity,  instinct  of,  and  emotion 
of  wonder,  234 
of  children,  21 
Cushing,    91,     110,     111,    113,     114, 
115,   116,  122,  244,  268,  269,  270, 
329 

Davenport,  252,  256 
Degeneratio  adiposogenitalis,  60,  68 
Delafield,  243 

Delinquency  and  crime,  255 
Dementia  prsecox,  58,  90 
Dercum,  58,  90 

Dermatoses  of  climacterium,   160 
Dermoid  cysts,  317 
Determination  of  sex,  57 
Determiners  of  character,  56,  57 
Development  of  breasts,  132 
Dilatation  and  curettage  in  sterility, 
171 
dangers  of,  184,  185 
Discipline,  6,  29 


INDEX 


479 


Disgust,  emotion  of,  and  instinct  of 

repulsion,  233 
Dock,  105 
Dominants,  57 
Dreams,  148 

endocrine  relation  in,  305 
Drugs     and     endocrine     action     in 

sleep,  311 
Dysmenorrhea,  65 

constitutional,  218 
hysterectomy  in,  224 
types,  diagnosis  of,  325 

placental  secretion  for,  205 
Dyspituitarism,  116 
Dystrophia      adiposogenitalis,      108, 

112,  321 

Early  habits,  14 

impressions,  6 
effects  of,  Henry  Adams  on,  20 
Eclampsia,  97 

acidosis  of,  211 

morphine  in,  214 

Murphy  drip  in,  211 

of  pregnancy,  207 

Csesarean   section   for,  211,  213 
spinal    puncture    for,    208,    214, 

216 
thyroid  extract  in,  213,  217 
Elation,  emotion  of,  and  instinct  of 

self-assertion,  234 
Embedding  and  nesting,  failure  of, 

as  cause  of  sterility,  178,  179 
Emotion   of  anger   and   instinct   of 
pugnacity,  234 

of  disgust   and  instinct  of  repul- 
sion, 233 

of  elation  and  instinct  of  self-as- 
sertion, 234 

of  fear,  79,  162,  163,  233 
and  instinct  of  flight,  233 

of  subjection  and  instinct  of  self- 
abasement,  235 

of    tenderness    and    parental    in- 
stinct,  235 

of  wonder  and  instinct  of  curios- 
ity. 234 


Emotional  antagonism  between  sym- 
pathetic   and    cranial    di- 
visions of  autonomic  sys- 
tem, 284 
and  sacral  divisions  of  au- 
tonomic system,  285 
Emotions  and  instincts,  232 
endocrine  balance  in,  291 
instincts  and  endocrines,  relation, 
238 
Encouragement,  40 
Endocrine  action  and  drugs  in  sleep, 
311 
balance  in  emotions,  291 
structures,  instability  of,  in  wom- 
an, 147 
system,  heredity  and,  8 
therapy  in  abortion,  179 
in  hyperthyroidism,  327 
in  'premenstrual  symptoms,  221 
in  sterility,  179,   180,  183,  190 
in  the  phobias,  277 
indications  for,  140 
Endocrines     associated     with     fear, 
273,  274,  275 
balance  between,  287 
effect  of  alcohol  on,  311 
higher  up  theory  of   sterility,   re- 
lation to,  17 
immunity  and  relation,  316 
in  gynecology,  135 
in  sterility,  141 
individual,  balance  in,  287 
influence  of  influenza  on,  12 
instincts    and    emotions,    relation, 

238 
relation  of,  to  sleep  and  dreams, 

305 
story  of,  introduction  to,  56 
therapeutic    suggestions    concern- 
ing, 314 
Endocrinology,  144 
Endometrium,    action    of    influenza 

on,  316 
Energy  and  thyroid  gland,  293 
Environment,  4 

Epilepsy  and  mental  deficiency,  254 
Epithelioma,  chorionic,  209,  317 


480 


INDEX 


Eppinger  and  Hess,  280 
Erdheim,  97 
Eunuchoidia,  151 
Eunuchs,  299 
Exophthalmos,  336 
Extract,  ovarian,  in  amenorrhea  of 
lactation,  68 
in  chlorosis,  68 
therapeutic  value  of,  323,  326 
pituitary,  63 

for  induction  of  labor,  204,  207 
placental,  71 

for  dysmenorrhea,  205 

for  glycosuria  of  climacterium, 

322 
for  menorrhagia,  206 
thymus,  70 

in  metrorrhagia,  71 
in  persistent  menorrhagia,  70 
thyroid,    in    eclampsia    of    preg- 
nancy, 213,  217 
therapeutic  value  of,  327 

Failure  of  embedding  and  nesting 

as  cause  of  sterility,  178,  179 
Fallopian  tubes  in  sterility,  178 
Falta,  341,  342,  343,  344,  345,  347, 

348,  350,  352,  353 
Fauser,  58 
Fear,  7,  9,  13,  162,  163,  233 

action  of  adrenals  in,  304 

corpus  luteum  in  relation  to,  273, 
276 

emotion  of,  and  instinct  of  flight, 
233 

pituitary  gland  in  relation  to,  278 

relation  to  physical  state,  9 
Fecundation,  56 
Feeble-mindedness,    grades    of,    252 

heredity  in,  253,  254,  256 

vs.  insanity,  250 
Female  coyness  and  sexual  jealousy, 

236 
Fibroids  in  sterility,  174 
Fibromata  of  uterus,  317,  318 
Fibromatous    nodules    in   uterus    in 

pregnancy,  302 


Flight,  instinct  of,  and  emotion  of 
fear,  233 

Flushes,  168 

Formative  type  of  mental  deficiency, 
262 

Frankel-Hochwart,  93,  97 

Freud;  15 

theory  of,  15,  16,  143,  307 

Frigidity,  145 

I'rohlich,  109 

Functional  type  of  mental  deficiency, 
262 

functioning  of  ovary  before  men- 
struation, 289 

Puture  of  child,  38 

General  questions   in   history  tak- 
ing, 332 

Genital  maturity,  age  of,  growth  of 
skeleton  and,  relation,  151 

Genitalia,    development    of,    glands 
associated  with,  163 

Gland    function,    instability   of,    in- 
herited, 85 

Glandular  therapy  of  sterility,  74 

Gley,  90 

Glycosuria,  105,  114,  117 
of     climacterium,     placental     ex- 
tract for,  322 
of  pregnancy,  202 

Goddard,  250,  253,  254,  255 

Gonads,  62 

Goodhart,  312 

Goodman,  89 

Gorst,  250 

Grades  of  feeble-mindedness,  252 

Granulosa  lutein,  63 

Graves'  disease,  99,  103 

Gregarious  instinct,  236 

Groos  (Karl),  232 

Gross  and  Tandler,  329 

Growth  and  hypophysis  gland,  294 
anterior    lobe    of   pituitary   gland 

and,  relation,  161 
posterior  lobe  of  pituitary  gland 

and,  relation,  161,  165 
of  body  during  pregnancy,  202 


